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http://www.archive.org/details/diseasesofchildhOOdonk 


THE 


DISEASES    OF    CHILDHOOD. 


THE 

DISEASES  OF   CHILDHOOD 

(MEDICAL) 


H.  BEYAN  DONKIN,  M.D.  Oxon.,  F.E.C.P. 

PHYSICIAN   TO   THE  WESTMINSTER  HOSPITAL  AND   TO   THE  EAST  LONDON  HOSPITAL  FOB 

CHILDREN   AT   SHADWELL  ;   JOINT-LECTURER  ON  MEDICINE  AND   CLINICAL  MEDICINE 

AT  WESTMINSTER  HOSPITAL   MEDICAL  SCHOOL. 


NEW    YORK: 
WILLIAM   WOOD   &   COMPANY. 

1893. 


311 


PREFACE. 


This  book  is  based  to  a  great  extent  on  the  records  and  recollec- 
tions of  nearly  twenty  years'  experience  at  the  East  London 
Hospital  for  Children  and  elsewhere,  and  includes  the  substance 
of  some  lectures  given  at  Westminster  Hospital  and  of  a  few 
contributions  to  the  Westminster  Hospital  Reports. 

Bound  by  prescribed  limits  of  space  as  well  as  by  the  publishers' 
requirement  of  a  clinical  work  for  practitioners  and  senior  students, 
I  have  assumed  the  reader's  general  knowledge  of  the  diseases 
discussed,  and  emphasised  only  the  points  pertaining  to  childhood. 
Projected  chapters  on  mental  disorders  and  on  affections  of  the 
skin  have,  moreover,  been  abandoned,  and  notices  of  '  variola '  and 
some  other  maladies,  of  which  my  personal  experience  has  been 
inconsiderable,  have  been  omitted. 

To  the  many  writers  and  teachers  whom  I  have  studied  and 
followed  but  few  references  have  been  made.  My  debts  to  them 
are  great  and  conspicuous ;  but  I  have  striven  throughout  to  avoid 
repetition  of  statements  howsoever  trite  on  authority  howsoever 
good  without  recourse  to  the  records  of  my  own  observations. 

My  sincere  thanks  are  due  to  many  Hospital  Residents,  especi- 
ally at  Shadwell,  who  have  materially  aided  me  in  the  collection 
of  cases  from  the  note-books.  From  three  successive  medical 
officers  there — Mr.  Scott  Battams,  Dr.  Hastings,  and  Dr.  Ware — 
I  have,  further,  received  important  help,  both  critical  and  clerical. 
To  Dr.  Hastings  a  special  expression  of  my  gratitude  is  offered 
for  his  friendly  assistance  in  the  work  of  proof-correction  and  for 
much  valuable  advice. 

I  am  deeply  obliged  to  several  other  friends  and  colleagues : — 
to  Mr.  J.  L.  Hague  for  having  kindly  relieved  me  of  the  laborious 
task  of  index-making ;  to  Dr.  J.  A.  Coutts  for  the  critical  reading 


VI  PREFACE. 

of  many  chapters ;  to  Dr.  E.  G.  Hebb  for  his  ever-ready  help  in 
matters  pathological;  to  Dr.  W.  A.  Wills  for  assistance  in  the 
collection  of  cases  from  the  Westminster  Hospital  Records ;  and 
to  Dr.  Sturges  and  Dr.  Eustace  Smith  for  permission  of  free  access 
to  their  respective  wards  at  Westminster  and  Shadwell. 

While  the  final  sheets  of  this  volume  were  passing  through  the 
press  a  valuable  Report  was  issued  by  the  Clinical  Society  of 
London  on  the  duration  of  the  periods  of  Incubation  and  Con- 
tagiousness in  certain  of  the  commoner  infectious  diseases.  Seeing 
that  this  Report  is  founded  on  material  which  was,  for  the  greater 
part,  either  entirely  new  or  inaccessible  to  earlier  writers,  and  that 
it  has  been  drawn  up  with  great  care  under  the  direction  of  a 
Committee  of  the  Society,  I  have  deemed  it  well  to  record  its 
main  conclusions  in  the  form  of  an  Appendix  to  Section  III. 
For  this  abstract  I  am  wholly  indebted  to  the  kindness  of  my 
colleague,  Dr.  Dawson  Williams,  whose  highly  important  part  in 
the  preparation  of  the  work  is  specially  acknowledged  by  the 
above-mentioned  Committee. 

H.  BEYAN  DONKIK 

London,  June  1893. 


CONTENTS. 


INTRODUCTION. 

PAGE 

Special   characteristics  of  disease   in  childhood— Clinical  examination  of 

children ,      . 1-4 


SECTION  I. —DISORDERS  OF  THE  ALIMENTARY  TRACT 
AND    OF    THE    ABDOMEN. 

CHAPTER  I. 

INFANTILE    WASTING. 

Causes  of  wasting — Normal  feeding  of  infants — Symptoms  of   wasting — 

Morbid  anatomy — Artificial  feeding 5-21 

CHAPTER  II. 

AFFECTIONS   OF   THE   MOUTH. 

Dentition  —  Stomatitis — Aphthous   stomatitis — Ulcerative   stomatitis — Noma — 

Thrush 21-30 

CHAPTER  III. 

AFFECTIONS   OF   THE   FAUCES. 

Acute  catarrh  of  pharynx — Acute  tonsillitis — Chronic  enlargement  of  tonsils — 

Retro -pharyngeal  abscess 3°~37 

CHAPTER  IV. 

GASTRO-INTESTINAL   DISORDERS. 
Vomiting — Diarrhoea — Acute  diarrhoea — Chronic  diarrhoea        .         .         .  38-59 

CHAPTER  X. 

GASTRIC   AND   INTESTINAL   DISEASE. 

Ulceration  of  stomach— Gastric  catarrh — Intestinal  catarrh  and  enteritis — 

Tubercular  disease  of  intestines         .......  59-67 


Vlll  CONTENTS. 

CHAPTEE  VI. 

CONSTIPATION. 

PAGE 

Definition — Causes — Treatment 67-72 

CHAPTEE  VII. 

INTESTINAL   OBSTRUCTION. 
Intussusception — Prolapse  of  rectum  ......  73—79 

CHAPTEE  VIII. 

PERITYPHLITIS   AND   TYPHLITIS. 
Symptoms  of  typhlitis — Calculous  disease  of  vermiform  appendix         .         79-83 

CHAPTEE  IX. 

PERITONITIS   AND   ABDOMINAL   TUBERCLE. 
Acute  peritonitis — Chronic  peritonitis — Tuberculous  disease  of  abdomen      83-88 

CHAPTEE  X. 

ASCITES,    JAUNDICE,   AND   DISEASES   OF   THE   LIVER. 

Ascites  —  Causes  and  treatment — Jaundice— Acute  yellow  atrophy — Fatty 
liver — Lardaceous  liver — Interstitial  hepatitis — Tumours  and  abscess 
of  liver 88-96 

CHAPTEE  XL 

ENLARGEMENT   OF   THE   SPLEEN. 
Splenic  ansemia — Leucocythcemia       ........        97-100 

CHAPTEE  XII 

URINARY    DISORDERS. 

Polyuria — Oliguria — Enuresis — Deposit  of  urates — Lithiasis — Renal  calculus — 

Haamaturia — Hemoglobinuria — Albuminuria  .....      100-108 

CHAPTEE  XIII. 

ANASARCA  AND   KIDNEY   DISEASE. 

Anasarca — Acute    nephritis — Chronic    nephritis — Tubercular  disease    and 

malignant  growth  of  kidney 108-113 

CHAPTEE  XIV. 

Worms — Tape-worms — Round-ioorms — Thread-worms         ....      113-115 
Concluding  remarks  on  the  diagnosis  of  abdominal  disease   .        .        .      11 5-1 16 


CONTENTS.  IX 


SECTION  II.— GENERAL  DISEASES. 

CHAPTER  I. 

RICKETS. 

PAGE 

Description — Symptoms  and  signs — Morbid  anatomy — iEtiology — "  Scurvy  - 

rickets" — Treatment 1 19-128 

CHAPTER  U. 
SYPHILIS. 

Origin   and   symptoms  of    infantile   syphilis — Relapse — "Late   hereditary 

syphilis" — Prognosis — Treatment i29-I39 

CHAPTER  III. 

SCROFULOSIS   OR   STRUMA. 
Description — Relation  to  tuberculosis — Treatment         ....       140-143 

CHAPTER   IV. 

TUBERCULOSIS. 

Forms  of  tuberculosis — Definition — General  or  acute  tuberculosis — Condi- 
tions of  tuberculosis  —  Chronic  tuberculosis  —  Prognosis  —  Treat- 
ment        144-148 

CHAPTER  V. 

ANAEMIA,   PURPURA,   AND   SCURVY. 

Antenna  — Hodgkins  disease  — Lcucocythcemia — Purpura  — Hcnmophilia — Pur- 
pura simplex — Purpura  hcemorrhagica — Purpura  fulminans — Scurvy      148-157 


SECTION  III— ACUTE  FEBRILE  DISEASES. 

CHAPTER   I. 

PYREXIA. 

Peculiarities  of  temperature  in  childhood — Subnormal  temperature — Pyrexia 
in  nervous  disorder — Multiform  conditions — Malarial  fever — Cutaneous 
redness  with  pyrexia — Wasting  with  pyrexia         ....         161-164 

CHAPTER    II. 

DIPHTHERIA. 

Description — Membranous  deposit,  diphtheritic  and  non-diphtheritic — 
Bacillary  origin — Sources  and  spread  of  the  contagium — Symptoms  and 
course — Mortality — Prognosis — Treatment 164-176 


X  CONTENTS. 

CHAPTER    III. 
SCARLATINA. 

PAGE 

The  scarlatinal  throat — Latent  scarlatina — General  symptoms — Diphtheria 
and  scarlatina — Albuminuria — Nephritis — "  Scarlatinal  rheumatism  " — 
Prognosis— Relapse — Contagion  and  incubation — Treatment        .        177-184 

CHAPTER  IV. 

MEASLES. 

Symptoms  and  course— Catarrh  of  the  respiratory  tract — Diarrhoea — Tuber- 
culosis and  measles — Paralytic  phenomena — Contagionandincubation — 
Treatment 184-189 

CHAPTER  V. 

RUBELLA, 

Difficulties  of  description  and  diagnosis — Varying  accounts  of  the  disease 

— Rarity  in  London  hospital  practice 189-193 

CHAPTER  VI. 

CHICKEN-POX,   MUMPS,    AND   INFLUENZA. 

Chicken-pox — Diagnosis — Incubation — Infection — Treatment — Mumps  —  Incu- 
bation— Infection— Treatment — Influenza — Characteristics  of  influenza  in 
children — Treatment  .........         193-199 

CHAPTER  VII. 

ENTERIC   FEVER. 

Incidence  and  mortality  in  childhood — Contagiousness — Duration — Tempe- 
rature— Sudden  onset — Diarrhoea  and  constipation— Bronchitis — Heart- 
affection — Nervous  symptoms — Relapse — Diagnosis — Treatment      .  199-208 

CHAPTER  VIII. 

RHEUMATISM   AND   ARTHRITIS   DEFORMANS. 

Rheumatism — Symptomatology — Incidence  at  various  ages — Heart-disease — Ar- 
thritis—  Temperature — Nodules — -Pleurisy — Nerve-disturbance  —  Prognosis 
— Treatment — Arthritis  deformans — Subjects  of  the  affection — Treatment  209-218 

CHAPTER  IX. 

WHOOPING-COUGH. 

Question  of  the  unity  of  this  affection — Course — Spread — Incubation- 
Incidence — Mortality — Prognosis — Treatment  ....     218-225 

APPENDIX. 

Abstract  of  the  conclusions  given  in  the  Report  of  a  Committee  appointed 
by  the  Clinical  Society  of  London  to  investigate  the  periods  of  incuba- 
tion and  contagiousness  of  certain  infectious  diseases      .         .         .      226  a-c 


CONTENTS.  xi 

SECTION  IV. 
DISORDERS  OF  THE  NERVOUS  SYSTEM. 

CHAPTER  I. 

SPASMODIC   DISORDERS. 

Infantile  convulsions— ^Etiology— Nervous  heredity— Rickets— Brain-affections 
—  Scquclce — Prognosis — Treatment  —  Tetany  —  Epilepsy  —  Characters  in 
childhood —  Diagnosis  —  Hysteria  and  epilepsy —  ^Etiology  —  Epilepsy  and 
hemiplegia  —  Epilepsy  and  syncope  —  Prognosis  —  Treatment  —  Localised 
spasms — Nystagmus — Hcad-jerJcing — Torticollis — Other  spasms — Retraction 
of  the  head        .........         .         .         230-247 

CHAPTER  II. 

THE   PARALYSES    OF   CHILDHOOD. 

Infantile  hemiplegia — Causes— Course — Sequelce — Prognosis — Treatment — Spas- 
tic paralysis — Infantile  spinal  paralysis — Symptoms — Conditions  and  ac- 
companiments of  onset — Morbid  anatomy — ^Etiology — Diagnosis —  Prognosis 
— Treatment — Chronic  paralysis  with  atrophy  of  muscles — Pseudo-hyper- 
trophic  paralysis — "Peroneal"  and  "juvenile"  types  of  amyotrophy — 
"  Diphtheritic "  paralysis         ........       247-270 

CHAPTER  III. 

ACUTE   DISEASES   OF   THE   BEAIN. 

Encephalitis— Acute  meningitis — Tubercular  meningitis — Meningitis  uncon- 
nected with  tubercle — Apparently  idiopathic  meningitis — Purulent  menin- 
gitis— Simple  acute  hydrocephalus — "  Hydrocephaloid  "  disease   .         .  271-28!; 

CHAPTER  IV. 

CHRONIC    DISEASES   OF   THE   BRAIN. 

Chronic  hydrocephalus — Cerebral  hasmorrhage — Thrombosis — Embolism 

Tumours — Characteristics  of  cerebellar  tumours — Sclerosis  of  brain    .      286-296 

CHAPTER  V. 

CHOREA. 

Description — Emotional  disturbance — Temperature — Recurrence — Rheuma- 
tism and  chorea — Heart-affection  and  chorea — Morbid  anatomy — Origin 
of  chorea — Nervous  relationships — Prognosis — Treatment      .         .      297-309 

CHAPTER  VL 

HYSTERIA  AND    FUNCTIONAL   NERVOUS   DISORDER. 

Description— Psychopathy — Maniacal  attacks — Motor  manifestations — Spasm 
— Catalepsy — Paralysis — Tremors — Sensory  disturbances — Anaesthesia — 
Hyperesthesia — Nervous  pyrexia — Diagnosis — Prognosis — Treatment  310-324 


Xll  CONTENTS. 

CHAPTER  VII. 

HEADACHE. 

PAGE 

Various  kinds  of  headache — Migraine 324~32^ 

CHAPTER  VIII. 

OTITIS. 
Symptoms — Frequent  latency  of  local  symptoms — Treatment      .         .         .      32Q-33° 

CHAPTER  IX. 

TETANUS. 
Microbic  origin — Tetanus  neo-natorum 33I-332 


SECTION  V. 
DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

Introduction — Examination  of  the  chest 335~337 

CHAPTER  I. 

AFFECTIONS    OF   THE   NOSE. 
Nasal  catarrh — Scrofulous  and  syphilitic  affections— Nasal  "  adenoids  "     337~338 

CHAPTER  II. 

LARYNGEAL  AND   LARYNGOTRACHEAL  AFFECTIONS. 

Warty  growths — Foreign  bodies — CEdema  of  larynx — Paralysis  of  abductors 
— Pharyngeal  abscesses  and  enlarged  glands  affecting  wind-pipe  — 
Laryngismus  stridulus — Glottic  spasm  with  laryngeal  catarrh — Acute 
laryngitis — Catarrhal  laryngitis — Membranous  laryngitis — Chronic  laryn- 
geal disease        339~352 

CHAPTER  III. 
TRACHEO-BRONCHIAL   CATARRH   AND   CHRONIC   BRONCHITIS. 

Catarrh  of  trachea  and  primary  bronchi — Chronic  bronchitis — Symptoms — 
Hereditary  tendency — Connexion  with  measles,  whooping-cough,  rickets — 
Collapse  of  lung — Emphysema — Bronchiectasis — Prognosis — Treatment     352-357 

CHAPTER  IV 

EMPHYSEMA   AND   ASTHMA. 

Emphysema — Subjects  of  emphysema — Primary  and  secondary  emphysema — 
Interstitial  emphysema — Asthma — Connexion  with  nervous  disorder — Gouty 
heredity — Enlargement  of  bronchial  glands 357-362 


CONTENTS.  Xlll 

CHAPTER  V. 

ACUTE   BRONCHITIS   AND    BRONCHO-PNEUMONIA. 

PAGE 

Close  connexion  of  bronchitis  and  broncho-pneumonia— iEtiology — Symp- 
toms of  acute  bronchitis— Collapse  of  lung — Varieties  of  broncho-pneu- 
monia— Symptoms — Morbid  anatomy — Incidence  on  age — Connexion  tvith 
tubercle  —  Chronic  broncho-pneumonia  —  Mortality  —  Prognosis  —  Treat- 
ment        362-372 

CHAPTER  VI. 

PNEUMONIA. 

Pneumonia  a  fever — etiology — Pneumonia  and  chill — Epidemic  form — Symp- 
toms and  signs — Incidence  on  age — Apex-pneumonia — Meningitis — 
Pleurisy — Diagnosis — Mortality — Treatment 372-379 

CHAPTER  VII. 

PLEURISY. 

iEtiology — Mostly  a  secondary  disease— Signs  and  symptoms  of  purulent  and 
non-purulent  pleurisy — Events  of  pleurisy — Diagnosis  —  Prognosis — 
Treatment 379-3S9 

CHAPTER  VIII. 

ON   PHTHISIS   AND   MEDIASTINAL   GLAND   DISEASE. 

Varieties  of  phthisis — Acute  miliary  tuberculosis — Ordinary  phthisis— Chronic 

phthisis — Diagnosis — Treatment — Disease  of  mediastinal  glands         .     389-401 


SECTION  VI. 
DISORDERS  OF  THE  HEART  AND  CIRCULATION. 

Introduction — Peculiarities  of  the  heart  and  circulation  in  childhood  .      405-406 

CHAPTER  I. 

CONGENITAL   HEART-DISEASE. 
Cyanosis — Symptoms  and  Signs — Morbid  anatomy — Prognosis       .         .     407-409 

CHAPTER  II. 

CARDIAC   INFLAMMATION   AND   VALVE-DISEASE. 

Myocarditis— Endocarditis  —  Valve-disease — 2Etiology — Prognosis  —  Treat- 

ment 410-416 


XIV  CONTENTS. 

CHAPTER  III. 

PERICARDITIS. 

PAGE 

Symptoms — iEtiology — Physical  signs — Prognosis — Treatment      .         .     417-422 

CHAPTER  IV. 

Raynaud's  disease. 

Description — Connexion  with  hemoglobinuria — Treatment   .         .        .     422-424 
INDEX 425 


DISEASES   OF   CHILDHOOD. 

(MEDICAL.) 
INTRODUCTION. 

"Without  personal  experience  and  careful  study  of  disease  as  it  appears 
in  early  life  the  practitioner  meets  with  many  difficulties  of  diagnosis 
and  treatment  which  are  not  to  he  coped  with  by  the  knowledge  gained 
from  the  practice  of  ordinary  hospitals  or  the  study  of  the  general  text- 
hooks  of  medicine.  There  is,  therefore,  a  clinical  reason  for  the  existence 
of  hospitals  and  even  hooks  devoted  to  the  disorders  of  children.  Doubt- 
less, however,  a  mindful  consideration  of  the  anatomy,  and  still  more  of 
the  physiology,  of  infancy  and  childhood  will  usefully  direct  the  studies 
of  those  who  are  well  acquainted  with  general  pathology.  Strictly 
speaking,  the  subject  of  disease  in  children  is  no  speciality,  and  it  may 
be  safely  assumed  that  however  great  the  practical  advantages  may  be 
of  special  hospitals  and  facilities  for  this  branch  of  clinical  study  the 
best  diagnosis  and  treatment  will  be  accomplished  by  those  who  have 
concurrent  experience  of  disease  in  general  at  all  times  of  life.  It  is 
mainly  in  the  practical  application  of  that  knowledge  which  should  be 
common  property  that  assistance  is  wanted  for  the  clinical  study  of  such 
disorders  as  are  prominently  incident  on  childhood  or  assume  a  special 
aspect  at  that  period. 

A  very  large  proportion  of  the  maladies  of  childhood  are  the  direct 
outcome  of  imperfect  and  at  the  same  time  rapidly  progressive  growth 
and  development.  Apart  from  congenital  malformations  there  is  a  con- 
stant liability  to  injury  from  external  stresses,  as  shown  so  markedly  in 
the  disorders  of  the  digestive  and  nervous  systems  in  infancy.  Eickets 
is  a  salient  instance  in  point,  and  it  Avill  be  seen  that  a  large  majority  of 
alimentary  and  nervous  disturbances  at  this  time  are  due  not  to  any 
primary  change  in  the  organs  concerned  but  to  untoward  strain  put 
upon  them  by  influences  from  without.  Gastric  and  intestinal  disorders 
evidenced  by  vomiting,  diarrhoea,  pain  or  other  symptoms  are  very  often 
directly  referable  to  ingesta  which  are  in  quantity  or  quality  unsuitable 
to  the  infantile  organs,  and,  unless  long  neglected,  are  frequently  curable 

A* 


2  INTRODUCTION. 

"by  obedience  to  simple  physiological  rules.  Again,  the  peripheral  ner- 
vous system  of  the  infant  is  in  developmental  advance  of  the  spinal;, 
and  both  are  far  ahead  of  the  higher  organs  of  brain  control.  Hence 
we  meet  with  numerous  instances  of  disorder  arising  from  what  are 
seemingly  the  slightest  and  often  undiscoverable  external  causes,  as  is 
evidenced  among  other  affections  by  convulsion,  readily  excited  febrile 
disturbance,  and  disordered  breathing.  Under  this  heading,  too,  we 
may  probably  rank  much  of  the  great  liability  of  young  children  to 
catarrh  of  mucous  membranes  arising  from  the  action  of  external  causes, 
such  as  changes  of  temperature,  on  the  nervous  periphery,  and  the  grave 
results  of  such  catarrh  in  the  respiratory  tract  leading  to  a  rapid  collapse 
of  the  lung  from  the  imperfectly  organised  nervo-muscular  mechanism 
of  breathing. 

Many  affections  which  are  not  confined  to  children  occur  with  so 
much  greater  frequency  in  early  life  that  they  are  practically  diseases  of 
childhood.  Of  such  are  many  of  the  exanthemata,  whooping-cough, 
membranous  and  other  forms  of  laryngitis,  certain  inflammatory  affec- 
tions of  the  brain  and  cord,  and,  among  other  intestinal  disorders,  intus- 
susception. Still  other  diseases,  such  as  tuberculosis,  rheumatic  fever, 
enteric  fever  and  lung-inflammations,  have  certain  peculiarities  more  or 
less  marked  in  childhood  which  give  them  a  claim  to  be  included  in  a 
special  work,  and  familiarity  with  such  affections  in  some  of  their  im- 
portant aspects  can  only  be  gained  from  extensive  experience  among 
children.  Besides  considerations  such  as  these,  most  writers  on  the 
subject  advance  a  further  apology  for  themselves  by  urging  the  special 
difficulties  which  beset  the  investigation  of  diseases  in  infancy  through 
the  inability  of  the  sufferers  to  give  account  of  their  feelings.  Not  to 
dwell  too  long  on  the  matter  of  the  examination  of  sick  children,  which 
is  ably  and  amply  and  sometimes  rather  tediously  treated  by  authors, 
I  shall  here  give  but  a  brief  sketch  of  what  seems  to  me  of  most  im- 
portance, leaving  it  to  be  more  or  less  filled  up  in  the  progress  of  the 
work  and  by  the  knowledge  or  common  sense  of  the  reader. 

In  all  cases  of  illness  in  children,  who  react  readily  to  but  very  slight 
disturbances,  the  most  careful  and  complete  examination  possible  should 
be  made  of  all  parts  and  organs,  and  all  deviations  from  normal  function 
noted.  For  this  it  is  necessary  that  the  observer  should  be  familiar  with 
the  healthy  appearance  and  habits  of  children  from  birth  onward.  The 
normal  changes  of  colour  in  the  skin  of  the  new-born  infant  must  be 
kept  in  mind,  the  characters  of  the  excreta  studied,  and  the  nature  of 
the  movements,  especially  of  the  eyes  and  limbs,  observed.  "Want  of  inti- 
mate acquaintance  with  the  normal  infant  may  lead  to  a  mistaken  diagnosis, 
healthy  and  morbid  signs  being  often  confused.  Full  attention  should 
always  be  paid,  Avith  due  critical  reserve,  to  anything  that  is  reported  as 


INTRODUCTION.  3 

abnormal  by  mother  pr  aurse,  for  though  frequently  coloured  by  fancy  or 
fright  their  statements  may  be  very  helpful  to  both  the  experienced  and 
the  inexperienced  doctor.  In  examining  a  child  it  is  well  to  postpone 
until  the  last  those  procedures  which  are  likely  to  be  felt  most  irksome, 
but  no  general  routine  need  be  prescribed.  As  a  rule  the  abdomen 
should  be  carefully  palpated  and  percussed  when  the  child's  attention  is 
distracted  and  before  it  is  stripped  for  that  general  inspection  which  is 
usually  necessary  on  a  first  visit,  if  not  afterwards  as  well ;  for  even  if 
the  child  do  not  cry  the  reflex  contractions  of  the  muscles  are  so  easily 
excited  by  handling  that  it  is  often  very  difficult  to  learn  much  of  the 
size  and  condition  of  the  abdominal  contents.  A  little  practice  and 
patience,  even  if  the  child  be  restless  or  crying,  will  generally  insure 
fairly  complete  auscultation  of  the  lungs  with  the  unaided  ear,  or  with 
the  stethoscope,  which,  in  the  case  of  less  disciplined  private  patients, 
should  for  preference  be  a  flexible  one ;  and  the  heart  can  be  listened  to 
with  some  success  under  similar  conditions.  The  time  for  percussion 
must  be  awaited,  as  a  rule,  until  the  child  be  quiet,  for  the  results  of 
this  method  of  examination  in  young  children  are  even  in  the  most 
favourable  circumstances  far  more  difficult  of  interpretation  than  those 
of  auscultation.  The  examination  of  the  mouth,  and  especially  of  the 
fauces  (which  should  never  be  omitted,  and  is  especially  valuable  in 
many  obscure  cases  of  pyrexia)  is  often  difficult  and  must  frequently  be 
forcible.  For  this  it  is  well  to  be  prompt,  causing  the  child's  head  and 
limbs  to  be  firmly  held,  and  pushing  the  spatula  or  spoon  well  back  on 
the  tongue.  Much  time  is  wasted  and  much  annoyance  given  to  the 
child  and  its  attendants  by  hesitating  and  feeble  attempts  to  inspect  the 
throat.  The  use  of  both  the  ophthalmoscope  and  the  laryngoscope  requires 
much  practice  when  the  patient  is  restless  or  too  young  to  co-operate  with 
the  observer,  and  is  often  impossible.  For  important  practical  purposes, 
however,  neither  of  these  instruments  is  often  necessary  in  the  case  of 
infants,  and  in  many  instances  of  cerebral  symptoms  which  call  for  the 
diagnostic  aid  of  the  ophthalmoscope  the  torpid  condition  of  the  patient 
renders  its  use  comparatively  easy. 

Thermometric  observation,  to  be  of  real  value,  should  not  be  made  in 
the  mouth,  but  either  in  the  rectum,  the  child's  body  being  kept  still  by 
one  hand  placed  on  the  abdomen,  or  by  carefully  holding  the  instrument 
in  the  axilla  or  groin  for  five  minutes  or  more,  according  to  its  sensi- 
tiveness. If  there  be  reason  to  suspect  pyrexia  from  a  rash  or  other 
symptoms  and  the  axillary  temperature  appear  normal  a  second  obser- 
vation should  always  be  taken  in  the  rectum. 

Details  of  what  to  observe,  of  the  deviations  from  the  normal  in 
external  appearance,  and  other  physical  signs  of  organic  disease  will 
be  given  when  the  various  groups  of  symptoms  pointing  to  general  or 


4  INTRODUCTION. 

local  disorder  are  considered.  I  will  only  add  here  that  in  dealing  with 
children  the  doctor  should  be  as  gentle  and  as  natural  as  possible  in 
manner  and  strive  to  drop  entirely,  if  he  have  ever  acquired,  that 
grave  professional  style  which  is  often  deemed  necessary  with  adult 
patients.  During  the  whole  of  the  visit,  and  specially  if  it  be  the  first, 
alertness  of  eye  and  ear  will  often  give  us  valuable  information,  and 
we  may  learn  much  before  the  child  be  touched  or  even  aware  that  it 
is  noticed. 

The  period  of  years  included  here  under  the  term  "  childhood "  ex- 
tends from  birth  to  the  usual  time  of  the  establishment  of  puberty 
which  may  be  roughly  set  down  to  the  fifteenth  year. 

"  Infancy  "  for  practical  purposes  is  to  be  understood  as  extending  to 
the  end  of  the  second  year  when  the  first  dentition  is  usually  complete. 
In  accordance  with  the  usage  of  my  colleague,  Dr.  Eustace  Smith,  I 
apply  the  term  "  early  childhood  "  to  the  next  two  years,  for  there  is  a 
marked  falling  off  in  the  incidence  of  several  disorders,  both  nervous, 
alimentary  and  pulmonary,  before  or  about  the  end  of  the  fourth  year. 


SECTION  I.— DISORDERS  OF  THE  ALIMENTARY 
TRACT  AND  OF  THE  ABDOMEN. 


CHAPTER  I. 


INFANTILE    WASTING. 


Wasting  in  infancy  as  the  result  of  insufficient  or  improper  food  is 
the  subject-matter  of  the  present  chapter.  Several  local  and  general 
diseases,  however,  are  most  prominently  evidenced  by  loss  of  flesh,  and 
we  must  never  be  content  with  the  diagnosis  of  simple  atrophy  from 
dietetic  causes  without  excluding  as  far  as  possible,  after  careful  exa- 
mination and  inquiry,  the  antecedence  or  concurrence  of  other  mischief. 
As  examples  of  some  among  many  affections  which  I  have  often  seen 
diagnosed  as  simple  wasting  in  infancy  and  early  childhood  I  may 
mention  not  only  tuberculosis  and  syphilis,  but  also  undiscovered  em- 
pyema without  marked  symptoms  or  pyrexia,  and  the  atrophic  sequela? 
of  enteric  and  other  fevers.  A  very  large  number,  however,  of  the 
deaths  of  children  in  their  first  year  is  due  to  starvation,  whether  caused 
by  insufficient  food  or  by  ingesta  which,  being  to  a  great  extent  indi- 
gestible or  unassimilable,  have  little  or  no  nutritive  value.  Innumer- 
able cases,  too,  of  rickets  and  other  disorders  are  either  largely  the  direct 
and  often  disastrous  results  of  improper  feeding,  or  are  favoured  in  their 
development  by  the  draining  and  starvation  of  the  body  arising  from 
the  frequently  consequent  diarrhoea  and  vomiting.  The  most  ordinary 
and  glaring  fault  in  feeding  infants  is  the  substitution  of  most  or  all  of 
the  requisite  milk  by  farinaceous  material,  which,  if  not  properly  cooked 
or  malted,  is  no  food  at  all,  and  at  the  best  is  half-starvation  diet.  It 
contains  practically  no  fat,  and  lacks  that  indefinite  antiscorbutic  quality 
which  is  essential  to  health. 

In  the  case  of  an  infant  healthy  at  birth  and  suckled  by  a  mother 
sound  in  body  and  mind  at  intervals  of  two  hours  gradually  increased 
to  three  hours  until  weaning-time,  there  is  the  least  to  fear  from  serious 
alimentary  trouble  leading  to  wasting.  The  mother's  milk  contains, 
of  course,  all  that  is  necessary  to  nutrition,  and  in  such  a  form  that 


6 


DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 


the  scanty  salivary  secretion  of  young  infants  and  the  small  power  of 
the  pancreatic  juice,  during  the  early  months,  of  turning  starch  into 
sugar  or  acting  upon  fat  have  as  yet  no  physiological  import.  The 
sugar  is  ready  formed  in  the  milk  which  contains  also  the  necessary 
salts,  the  fat  is  easily  assimilable,  and  the  gastric  juice  of  the  infant  is 
in  full  activity  to  deal  with  the  proteid  casein.  That  the  infant  requires 
much  more  fat  and  less  carbo-hydrate  in  proportion  to  proteid  food  than 
the  adult,  and  a  greater  proportion  of  water,  is  shown  by  the  following 
figures  which  I  quote  from  the  averages  drawn  by  Dr.  Cheadle  from 
standard  analyses  of  human  milk  and  from  estimations  of  the  physio- 
logical requirements  of  adult  diet.  These  data  may  be  regarded  as 
sufficiently  accurate  for  the  establishment  of  the  above-mentioned  con- 
clusions, but  partake  too  much  of  the  artificial  nature  of  all  physiological 
averages  to  be  rigidly  applied  as  a  standard  in  individual  cases. 

In  human  milk,  to  which  of  course  all  imitation-  or  substitution- diets 
for  infants  should  conform  as  far  as  possible,  the  percentage  of  the 
elements  is  as  follows  : — 


Proteid 

Fat 

Carbo-hydrates 

Salts 

Water 


3-Soo 

3.000 

4.000 

.138 

89.362 


The  standard  requirements  for  adults  are  thus  proportioned : — 


Proteid 

Fat 

Carbo-hydrates 

Salts 

Water 


5.00 

3.00 

15.00 

i,i*5 

75-85 


The  remembrance  of  the  above  formula  for  infantile  diet,  together 
with  that  of  the  fact  that  about  a  pint  of  fluid  so  constituted  is  the 
daily  amount  necessary  for  an  average  infant  during  the  first  month, 
will  remind  us  of  the  theoretically  proper  though,  as  we  shall  see,  not 
always  practicable  dilution  of  the  various  articles  of  food  which  we  may 
have  to  use  in  substitution  of  mother's  milk.  After  the  age  of  one 
month  until  the  sixth  is  reached  the  quantity  of  this  nourishment  should 
be  gradually  increased  to  about  two  pints,  and  two  and  a  half  pints  or 
even  more  may  be  taken  after  the  tenth  month.  The  intervals  of  feeding 
should  at  first  be  about  every  two  hours,  and  later  somewhat  longer, 
according  always  to  those  requirements  of  the  individual  case  which  can 
be  learnt  by  experience  alone.     In  this  context  the  following  Table,  taken 


INFANTILIS  WASTING. 


from  an  article  by  Dr.  Emmett  Holt  in  Heating's  Cyclopedia  of  the 
Diseases  of  Children,  and  based  on  the  ascertained  weight  of  a  number 
of  healthy  infants  before  and  after  nursing,  is  valuable  as  indicating 
the  approximate  quantity  for  the  meals  of  average  infants,  although, 
according  to  my  experience,  children  over  six  months  can  very  often 
take  more  with  advantage. 


Age. 

One  Feeding. 

Number  of 
Feedings. 

Daily  Amount. 

Oz. 
16 
24 

28 

30 

33-36 

35-38 

40 

2  weeks     . 

1  month    . 

2  months  . 
4       „ 

6       ,, 
9       „ 

12          ,, 

Oz. 
2 

3 
4 
5 
54-6 

7~7h 
8-9 

8 
8 

I 

6 
5 
5 

Certain  conditions  of  the  mother's  milk,  as  regards  quantity  or  quality, 
may  render  it  unfit  or  insufficient  food  for  the  child,  and  either  a  wet- 
nurse  or  artificial  feeding  must  be  resorted  to  if  a  short  trial  of  suckling 
result  in  nutritive  failure  as  shown  by  wasting  or  much  discomfort,  or 
still  more  by  persistent  vomiting,  unhealthy  motions  or  diarrhoea.  If, 
however,  the  breast-milk  be  deficient  in  quantity  only,  or  the  mother  be 
otherwise  unable  to  suckle  the  child  sufficiently  often,  alternate  suckling 
and  artificial  feeding  are  far  better  than  weaning. 

An  infant  is  not  likely  to  thrive  well  on  the  milk  of  a  mother  who  is 
suffering  from  syphilis  or  tuberculosis.  Apart  from  the  discovery  of 
definite  ill-effects  we  are  always  justified  in  advising  that  the  children  of 
such  mothers  should  be  otherwise  fed.  Repeated  emotional  disturbances 
or  febrile  illnesses  on  the  part  of  the  mother  are  frequently  accompanied 
by  some  modification  of  the  milk  which  causes  digestive  disorder  in  the 
child,  and  there  are  cases  where  an  analysis  of  the  milk  shows  that  the 
various  elements  are  in  too  great  or  too  small  proportion  for  due  nutrition, 
thus  accounting  for  alimentary  disorder  or  wasting  and  pointing  to  a 
change  of  diet. 

The  most  cases  by  far  of  simple  infantile  wasting  are  met  with  in  the 
poorest  classes  and  are  largely  due  either  to  chronic  under-feeding  and 
weakness  of  mothers  who,  from  their  very  poverty,  persist  in  nursing 
their  infants,  or  to  the  calls  of  daily  work  which  hinder  regular  nursing 
and  necessitate  substituted  or  additional  diets  that  are  usually  of  im- 
proper quality  and  practically  innutritious.  Among  the  more  fortunate 
classes  mothers  Avho  do  not  nurse  their  children  frequently  engage  a  wet- 
nurse  or  avail  themselves  of  the  best  instructions  as  to  artificial  feeding. 
The  labouring  classes  are  thus  forced  to  supply  a  very  large  contingent 


5        DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

to  the  population  of  starved  and  diseased  children,  for  wet-nursing,  of 
course,  and  often  even  the  purchase  of  enough  good  milk  for  approxi- 
mately efficient  nutrition  are  out  of  their  power.  "Wasting  cases,  how- 
ever, occur  not  only  when  the  mothers  cannot  but  also  when  they  will 
not  suckle  their  infants,  and  the  children  of  many  well-to-do  people  fail 
under  the  stress  of  artificial  feeding  ignorantly  or  carelessly  directed. 

Loss  of  weight  and  fretfulness  are  the  leading  symptoms  of  atrophy 
due  to  insufficiency  of  proper  food.  The  normal  child  should  increase  in 
its  first  month  by  about  one-third,  in  half  a  year  by  more  than  double, 
and  in  one  year  by  treble  its  original  weight ;  but,  without  weighing, 
wasting  is  usually  apparent  from  the  more  or  less  rapid  disappearance  of 
fat  from  all  parts  of  the  body.  The  face  becomes  peaked  and  wears  an  old 
and  anxious  appearance ;  the  fontanelle  is  depressed ;  the  child  is  con- 
stantly crying  and  sucking  its  fingers  or  anything  on  which  it  can  lay  hold  ; 
the  skin  is  pale,  dry,  and  wrinkled,  loses  its  elasticity,  and  may  show  fine 
desquamation.  Some  infants  may  thus  continue  wasting  without  further 
marked  symptoms  until  drowsiness  sets  in  upon  extreme  weakness,  and 
with  all  the  wheels  of  being  running  slower  and  slower  they  may  die 
unnoticed  in  their  sleep.  Sometimes  almost  sudden  death,  as  observed 
by  Mr.  Scott  Battams,  may  result  from  collapsed  lung,  many  children 
having  thus  succumbed  at  Shadwell  Hospital  during  the  small  hours  of 
the  morning  when  vitality  is  normally  at  its  lowest  ebb.  Much  more 
often,  however,  further  disturbances  are  observed.  Progressive  ansemia 
and  weakness  cause  indigestion  of  the  little  food  taken,  and  vomiting 
accelerates  the  process  of  the  malady.  If  the  diet  be  milk  it  is  ejected 
in  unchanged  curds,  and  when  indigestible  food  has  been  given,  as  is  the 
case  in  so  many  instances  of  hand-fed  children,  the  symptoms  of  irrita- 
tion of  the  alimentary  canal  are  seen  earlier  and  persist.  The  tongue  is 
furred  ;  vomiting  is  frequent  or  constant  after  food,  the  ejecta  often 
having  an  excess  of  mucus  and  a  sour  offensive  smell ;  the  belly  is 
frequently  distended  with  gases  and  somewhat  tender,  and  there  are 
facial  signs  of  abdominal  distress.  Diarrhoea,  too,  is  very  common,  the 
motions  losing  their  healthy  consistency  and  yellow  colour  and  becoming 
watery  and  often  green,  with  sour  smell  and  highly  acid  reaction.  With 
these  dyspeptic  symptoms  the  appetite  sometimes  fails  or  ceases  alto- 
gether ;  the  temperature  tends  to  fall,  and  in  some  extreme  cases  may 
be  below  900  F. ;  the  heart's  beats  become  fewer  and  the  respiration 
shallower ;  thrush  may  appear  in  the  mouth ;  the  extremities  grow  cold 
and  blue,  and  the  child  dies,  sometimes  in  a  convulsion.  In  many  cases, 
however,  the  appetite  may  be  ravenous  while  the  wasting  progresses. 
The  ingesta  remaining  long  in  the  stomach  and  intestines  there  is  acid 
fermentation  and  consequent  flatus  with  much  pain  which  seems  to  be 
temporarily  relieved  by  renewed  feeding. 


INFANTILE  WASTING.  9 

It  is  unnecessary  here  to  give  a  more  detailed  account  of  the  varying 
symptoms  and  course  of  untreated  or  maltreated  wasting  which  depend 
so  much  on  the  individual  powers  of  resistance  and  the  nature  of  the 
ingesta  with  which  attempts  at  nourishment  are  made.  The  subject  will 
be  further  dealt  with  under  the  clinical  headings  of  Diarrhoea  and 
Vomiting.  If  a  child  be  fed  on  milk  which  is  poor  or  insufficient  in 
quantity,  as  so  often  happens,  or  on  any  diet  which  is  deficient  in  the 
fatty  element,  there  may  be  no  vomiting  or  diarrhoea,  as  we  have 
already  seen,  or  at  all  events  not  for  long,  and  there  is  frequently 
constipation.  Irritating  substances,  such  as  unchanged  starch  which 
is  one  of  the  commonest,  or  masses  of  any  food  which  the  individual 
stomach  cannot  deal  with  will  cause  vomiting  and,  probably,  diarrhoea. 
The  less  vomiting  or  diarrhoea  there  has  been  the  better  is  the  prognosis 
when  the  case  comes  under  treatment,  but  in  many  of  even  the  apparently 
worst  instances  with  almost  a  skeletal  appearance  there  is  considerable 
ground  for  hope,  and,  in  the  absence  of  evidence  of  other  disease,  we  are 
often  justified  in  soon  making  a  highly  favourable  forecast. 

Post-mortem  examination  shows  in  many  instances  nothing  but  uni- 
versal wasting  and  anaemia  even  when  there  has  been  much  diarrhoea 
and  vomiting ;  in  some  protracted  cases,  however,  signs  of  chronic  in- 
testinal catarrh  or  occasionally  even  small  superficial  ulcers  may  be 
found.  Taking  into  consideration  the  very  frequent  absence  of  any 
notable  change  in  the  stomach  or  intestines  and  the  fact  that  many 
severe  cases  of  wasting,  even  with  long-continued  diarrhoea  and  vomit- 
ing, often  start  on  the  road  to  recovery  in  the  course  not  of  weeks, 
but  of  clays,  when  properly  treated,  I  have  long  been  of  opinion  that 
catarrh  of  the  stomach  or  intestines  plays  a  much  less  important  part 
than  is  often  taught  in  the  cases  we  are  considering,  and  that  when  it 
does  occur  it  is  the  result  of  continued  irritation  from  undigested  and 
fermenting  substances  in  the  alimentary  canal.  On  this  point  I  am 
therefore  in  accord  with  Professor  Henoch,  who  has  recourse  to  the 
older  chemical  theory  of  acid  fermentation  to  explain  the  common  char- 
acteristics of  the  vomit  and  faeces  in  cases  such  as  these.  A  certain 
degree  of  catarrhal  flux  may  result  from  the  irritation  of  the  gastric 
mucosa  by  indigestible  material,  and  this  alkaline  fluid  may  assist  in 
neutralising  the  gastric  juice  and  thus  favour  fermentation ;  but  it  is 
greatly  surprising  to  the  inexperienced  how  very  frequently  the  simple 
administration  of  dduted  milk  in  small  quantities,  or  the  substitution 
of  a  little  whey  or  dissolved  white  of  egg,  or  indeed  the  ingestion  of 
scarcely  anything  but  water  for  a  day  or  two  will  quickly  remove  all 
untoward  symptoms  and  prepare  the  child  to  receive  its  duly  nutritive 
diet.  A  chronic  gastric  catarrh — and  it  is  with  chronic  cases  that  we  are 
dealing  now — could  scarcely  be  cured  so  simply  or  so  soon. 


IO        DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

There  is  one  very  common  cause  of  the  dyspeptic  disturbances  and 
consequent  wasting  of  hand-fed  children,  apart  from  any  obviously  bad 
quality  of  the  food  given.  Want  of  cleanliness  of  the  bottle  or  feeding- 
tubes  (which  may  but  contain  the  stale  remains  of  milk)  often  occasions 
disturbance  by  allowing  the  direct  entrance  of  deleterious  germs  into 
the  stomach.  A  certain  number  of  cases,  of  less  intensity  than  those 
generally  known  as  summer  diarrhoea  or  "  cholera  infantum,"  which  are 
in  all  probability  due  to  the  action  of  morbific  organisms  can  be  rapidly 
cured  by  attention  to  this  point. 

Such  are  the  leading  symptoms  and  causes  of  atrophy  from  insufficient 
nutrition  without  antecedent  disease.  It  must  never  be  forgotten  that 
in  a  large  proportion  of  wasting  infants  among  the  poor  the  deprivation 
of  sunlight  and  of  wholesome  air  and  many  positive  evils  besides  con- 
tribute greatly  through  lowered  general  vitality  to  the  digestive  and 
assimilative  failure  of  these  victims  of  heredity  and  environment,  and 
hinder  or  prevent  their  response,  even  in  the  absence  of  special  gastric 
affections,  to  the  most  approved  and  careful  treatment. 

The  question  of  the  treatment  of  these  cases  of  wasting  mainly  resolves 
itself  into  that  of  correcting  the  child's  diet  according  to  physiological 
principles  either  by  way  of  supplementing  its  natural  diet  or  substituting 
an  artificial  regimen. 

I  shall  leave  for  subsequent  notice  those  temporary  digestive  disturb- 
ances, whether  catarrhal  or  otherwise,  which  from  time  to  time,  apart 
from  apparent  dietetic  errors,  may  interfere  with  nutrition,  only  empha- 
sising here  the  fact  that  in  the  first  year  such  disturbing  causes  are  not 
very  frequent  in  children  duly  fed  and  cared  for. 

When  a  systematically  suckled  infant  with  no  sign  of  other  disease 
fails  to  thrive  we  must  consider  what  can  be  done  to  secure  success 
before  giving  the  order  to  wean,  for  the  natural  food  should  never  be 
lightly  forbidden.  If  the  mother  be  healthy  and  her  milk  plentiful 
and  given  with  due  intervals  there  may  be  some  excess  or  defect  in 
the  nitrogenous  or  fatty  elements  of  the  milk.  This  may  be  ascer- 
tained by  analysis,  and  at  any  rate  intermediate  meals  of  cow's  milk 
properly  diluted  as  hereafter  to  be  described  may  be  tried  for  a 
while,  or  artificial  feeding  or  possibly  wet-nursing  altogether  may  be 
temporarily  resorted  to.  A  doctrinaire  dieting  of  the  mother  with  a 
view  to  modifying  her  milk  has  seldom  a  successful  and  often  a  bad 
result,  by  interfering  with  her  digestion,  and  I  Avould  incidentally  re- 
mark that  all  attempts  at  medication  of  the  infant  by  dosing  the  mother 
are  to  be  condemned  as  useless  or  pernicious  trifling.  An  increase  of 
the  fat  in  the  milk  may  be  attained  in  some  cases  by  a  richer  nitro- 
genous .diet  on  the  mother's  part.  The  best  way  for  the  mother  to 
secure  a  good  milk-secretion  is  to  indulge  in  a  plentiful  mixed  diet  with 


INFANTILE  WASTING.  I  I 

no  stint  of  fluid  and  no  more  alcohol  than  what  she  may  take  in  modera- 
tion at  other  times;  to  take  plenty  of  exercise  in  the  fresh  air;  and  to 
obey  generally  the  known  laws  of  health.  If  a  woman  cannot  so  order 
her  habits  and  be  unable  or  unwilling  to  prefer  the  function  of  nursing 
before  all  things  else  for  the  allotted  time  it  were  better  for  the  child 
to  run  the  risk  of  hand-feeding  from  its  start  in  life.  If  the  breast-milk 
be  deficient  in  fat  a  certain  amount  of  cream  may  be  given  to  the  child 
at  intervals,  and,  should  the  albuminous  elements  be  in  excess,  and  thus 
cause  difficult  digestion,  the  method  devised  by  Dr.  Eustace  Smith  may 
be  tried  of  giving  the  child  a  diluent  draught  of  barley-  or  lime-water  or, 
I  would  add,  of  water  alone,  just  before  putting  it  to  the  breast.  With 
this  aid  the  otherwise  too  indigestible  curd  may  often  be  successfully 
dealt  with.  When  the  mother's  milk  is  altogether  too  poor  and  scanty 
in  spite  of  careful  diet  and  other  hygienic  measures,  and  especially  when 
even  the  few  breast-meals  that  the  child  may  have  in  addition  to  other 
milk  appear  to  disagree  as  well  as  to  be  unsatisfying,  wet-nursing  or 
weaning  should  be  at  once  established. 

Most  cases  of  atrophy,  however,  occur  when  appropriate  breast-feeding 
is  out  of  the  question  owing  to  the  mother's  inability  or  disinclina- 
tion to  suckle  her  child  entirely.  Wet-nursing  doubtless  gives  a  child 
the  best  chance  of  progress  without  drawbacks,  but  there  are,  in  my 
opinion,  so  many  difficulties  and  objections  both  medical  and  socio- 
logical attaching  to  this  question,  that  Avith  an  expression  of  general 
•disapproval  of  this  method  I  shall  pass  on  to  the  matter  of  artificial 
feeding. 

Cow's  milk,  with  of  course  the  cream,  duly  diluted  with  a  regard 
to  both  general  physiological  principles  and  individual  possibilities  is 
practically  the  only  basis  for  hand-rearing  owing  to  its  very  ready 
supply  as  well  as  to  its  generally  best  qualities  in  spite  of  certain  faults. 
Goat's  milk  is  richer  in  fat  than  cow's  milk  and  therefore  good  food  for 
healthy  children  and  possibly,  for  some  cases  of  weakly  infants,  but  it 
has  no  advantage  over  cow's  milk  as  regards  the  indigestibility  of  its 
curd  in  comparison  Avith  that  of  human  milk.  Ass's  milk  has  a  very 
easily  digestible  curd,  but,  being  probably  no  richer  in  nutritive  qualities 
than  cow's  milk  diluted  with  two  parts  of  water  and  much  poorer  than 
human  milk,  can  only  be  of  temporary  use  in  cases  of  feeble  digestion 
and  is,  further,  very  expensive. 

Exceptionally  robust  infants  may  occasionally  do  well  on  almost  or 
quite  undiluted  cow's  milk  provided  no  cream  be  abstracted,  but  the 
average  baby  will  fail  to  digest  it  for  any  length  of  time.  Although 
the  amount  of  fat  is  practically  the  same  in  cow's  and  human  milk  the 
former  is  richer  in  proteids,  poorer  in  sugar,  and  has  a  slightly  acid 
instead  of  a  slightly  alkaline  reaction.     Its  casein,  too,  coagulates  in  much 


I  2         DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

larger  curds,  causing  difficulty  in  digestion.  Besides  this,  cow's  milk  as 
usually  obtained  several  hours  after  leaving  the  udder  contains  (and  espe- 
cially in  the  warmer  season)  many  bacteria,  some  of  them  probably  more 
or  less  morbific,  and  may  in  certain  circumstances  be  infected  with  the 
germs  of  tubercle,  scarlatina,  enteric  fever  or  other  specific  diseases. 

To  adapt  cow's  milk,  therefore,  to  the  infantile  needs,  we  must  (i) 
dilute  to  reduce  the  amount  of  proteids,  (2)  endeavour  to  promote  the 
digestibility  of  the  curd,  (3)  add  some  sugar,  (4)  boil  or  otherwise 
sterilise,  and  (5)  render  it  of  slightly  alkaline  reaction. 

The  two  points  of  dilution  and  curd-digestibility  may  be  considered 
together.  It  will  be  seen  at  once  that  dilution  which  may  duly  reduce 
the  proportion  of  casein  will  unduly  reduce  that  of  the  fat  and  other 
solids,  and  further,  that  even  if  the  reduction  of  the  fatty  element  be 
compensated  by  the  addition  of  cream  a  much  larger  quantity  of  fluid 
than  the  necessary  quantity  of  mother's  milk  must  be  ingested  in  order 
to  obtain  the  due  amount  of  albuminoid  food.  N^ow  the  difficulty  here 
raised  seems  very  great,  and  it  is  further,  I  think,  magnified  by  those  who 
rely  for  their  clinical  data  on  hard  and  fast  analytical  statements  as  to  the 
normal  proportions  of  the  various  ingredients  in  human  and  cow's  milk 
respectively,  omitting  perhaps  to  remember  the  greatly  varying  relative 
quantities  of  these  ingredients  in  human  and  cow's  milk,  and  also  in 
individual  women  and  individual  cows,  as  well  as  the  fact  that  the  milk 
of  both  women  and  cows  is  much  richer  in  solids,  and  especially  in  fat, 
at  the  end  of  the  milking  process  and  when  the  intervals  of  milking  are 
short.  In  illustration  of  the  great  theoretical  difficulty  that  all  students 
must  meet  with  in  this  matter  of  dilution  I  will  but  refer  to  two 
standards  given  respectively  as  a  basis  for  action  by  Dr.  Cheadle  in 
London  and  Dr.  Rotch  in  Boston,  U.S.A.  The  former  quotes  the 
relative  proportions  of  proteids  in  cow's  and  woman's  milk  as  5.404  to 
3.924,  while  the  latter  gives  it  as  4  to  2  or  1.  It  is  plain  that  here  as 
elsewhere  biologico-chemical  averages,  owing  to  the  complexity  of  their 
data,  are  not  of  paramount  value  for  practical  application  to  individual 
cases.  My  own  experience  fully  corroborates  this  and  justifies  me  in 
saying  that  as  a  rule  it  is  not  necessary  to  weaken  the  best  cow's  milk 
so  much  as  by  two  parts  of  water  or  other  diluent  except,  perhaps,  in 
some  few  cases  in  the  first  weeks  of  life,  and  that  even  when  such  dilu- 
tion is  found  necessary,  a  slightly  increased  quantity  at  all  meals  and 
shorter  intervals  between  them  (as  compared  with  what  natural  suckling 
would  indicate)  go  far  towards  overcoming  the  objection  of  giving  to  the 
infant  a  considerably  larger  amount  of  fluid  as  a  whole  than  it  might  take  at 
the  breast  in  twenty-four  hours.  If  cows  and  women  and  milk  and  babies 
were  all  constant  quantities  our  confessed  difficulty  in  the  hand-rearing  of 
human  young  on  cow's  milk  would  probably  be  as  great  in  practice  as  it 


INFANTILE  WASTING.  I  3 

seems  to  be  on  paper.  The  comparatively  indigestible  nature  of  the  larger 
curds  of  cow's  milk  is  perhaps  the  most  important  factor  after  all  in  this 
problem  of  dilution.  In  some  cases  indeed  of  wasting  and  alimentary  dis- 
turbance the  difficulty  is  almost  insoluble  and  among  other  causes  often 
necessitates  a  substitution-diet.  It  is  usually  taught  that  if  lime-water  or 
barley-water  be  used  in  varying  proportions  with  pure  water  as  diluents 
the  curd  becomes  finer  and  therefore  more  digestible ;  but  from  repeated 
experiments  I  have  found,  as  Dr.  Eotch  found,  that  outside  the  body 
there  is  practically  no  difference  in  the  appearance  of  the  clots  of  milk 
formed  by  acetic  acid  whether  in  mixture  with  water  alone  or  with 
barley-  or  lime-water,  and  I  have  never  known,  even  in  cases  when  con- 
tinued and  careful  observation  was  possible,  that  a  chdd  who  persistently 
vomited  hard  curd  when  fed  on  milk  well  diluted  by  water  ceased  to  do 
so  when,  without  any  other  change  in  treatment,  lime-  or  barley-water 
was  wholly  or  partially  substituted  for  the  original  diluent.  When  the 
digestibility  of  the  curd  is  not  attained  by  simple  dilution  pancreatised 
milk  may  be  used  with  advantage.  To  prepare  this,  a  pint  of  milk, 
according  to  Sir  William  Eoberts,  is  diluted  with  a  quarter  of  a  pint 
of  water  and  heated  to  about  1400  F.  Two  teaspoonfuls  of  Benger's 
"  liquor  pancreaticus  "  with  twenty  grains  of  bicarbonate  of  soda  are 
then  added  and  the  mixture  is  poured  into  a  covered  jug  which  is 
placed  in  a  warm  situation  to  keep  up  the  heat.  After  an  hour  or  an 
hour  and  a  half  the  produce  is  raised  to  the  boiling-point  to  prevent 
further  action  of  the  ferment.  The  milk  can  then  be  used,  further 
diluted  or  not,  according  to  circumstances.  Another  method,  often  very 
useful,  of  promoting  digestibility  of  the  curd  is  to  mix  with  the  milk  a 
small  quantity  of  well-baked  flour  or  of  one  of  the  best  prepared  farina- 
ceous foods.  About  a  teaspoonful  of  such  an  addition  to  five  or  six 
ounces  of  milk  is  frequently  found  to  have  good  effect.  I  have  said  that 
it  is  unpractical  to  lay  down  very  hard  and  fast  rules  as  to  the  quantity 
of  milk  to  be  taken  in  twenty-four  hours  by  any  given  child  in  view  of 
the  variability  of  requirements  and  digestive  power,  but  have  practically 
found  that  from  three-quarters  of  a  pint  to  a  pint  of  cow's  milk  diluted 
to  about  twice  its  bulk  will  usually  suit  the  youngest  babies,  if  given  in 
divided  doses  about  every  two  hours  or  sometimes  oftener,  although 
such  meals  may  be  larger  in  quantity  than  is  naturally  indicated.  Both 
the  quantity  and  dilution  may  have  to  be  frequently  altered  in  either 
direction,  and  each  case  must  be  carefully  studied  on  its  own  merits, 
especially  at  the  outset.  By  these  means  much  more  success  will  be 
attained  than  by  the  prescription  of  any  tabulated  routine  however 
elaborately  Avorkecl  out  on  the  system  of  averages.  Begurgitation  of 
milk  immediately  after  a  meal  means  that  the  stomach  has  been  over- 
filled, and  usually  indicates  less  abundant  meals  with  probably  shorter 


14         DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

intervals.  When  a  healthy  child  has  arrived  at  the  age  of  about  three 
months  it  is  almost  always  able  to  digest  milk  diluted  by  one-third 
only  of  water,  an  approximately  perfect  diet. 

The  deficiency  of  sugar  in  cow's  milk  is  theoretically  best  compensated 
by  the  addition  of  sugar  of  milk,  but  a  small  quantity  of  cane-sugar  in 
each  bottle  (just  sufficient  to  give  a  slight  sweet  taste)  usually  answers 
all  practical  purposes.  Pure  cow's  milk  is  at  least  2  per  cent,  lower  in 
sugar  than  human  milk,  and,  diluted,  of  course  still  lower. 

To  prevent  decomposition  by  destroying  germs  all  milk  given  to 
infants  should  be  sterilised  by  boiling  or  steaming.  The  milk  should  be 
thus  treated  as  soon  as  received  twice  a  day,  and  kept  in  a  receptacle 
carefully  stoppered  with  cotton  wool.  If  the  steaming  process  be 
adopted  it  is  well  to  place  the  feeding-bottles  containing  the  milk  in  the 
steamer,  the  nipples  being  protected  by  an  indiarubber  cap,  thus  pre- 
venting the  necessity  of  pouring  the  milk  from  one  vessel  to  another 
before  using  it.  A  convenient  method  of  steaming  milk  is  detailed  by 
Dr.  Eotch  in  an  article  in  Keating's  Cijclojpcediaori  "  Infant  Feeding,"  to 
which  I  would  refer  the  reader  on  this  and  other  points.  His  steamer 
consists  of  a  tin  pail  eight  or  nine  inches  in  diameter  and  nineteen  or 
twenty  inches  deep,  raised  on  three  legs  sufficiently  high  to  allow  a 
Bunsen  gas-burner  (or  spirit-lamp)  to  stand  under  it.  Four  inches  from 
the  bottom  of  the  cylinder  is  a  perforated  tin  diaphragm  on  which 
the  milk-receptacle  or  the  feeding-bottles  stand  while  being  sterilised. 
There  is  a  small  vent  in  the  cover  for  the  escape  of  steam.  "Water  is 
placed  in  the  steamer  to  the  depth  of  about  one  inch.  After  the  water 
has  been  boiling  a  few  minutes  the  vessels  containing  the  milk  are  put 
into  the  steamer  and  allowed  to  remain  for  twenty  minutes.  A  readier 
form  of  steriliser,  Dr.  Eotch  adds,  is  a  simple  colander,  with  a  lid, 
placed  on  a  kettle.  If  the  milk  be  sterilised  in  a  vessel  containing  a 
larger  quantity  than  is  enough  for  one  meal  the  receptacle  should  be 
carefully  stoppered  with  cotton  wool  and  kept  cool,  and  the  feeding- 
bottles  thoroughly  scalded  out  immediately  before  use.  Another  method 
of  sterilising  is  immersion  of  the  feeding-bottles  containing  the  milk  in 
boiling-water  for  thirty  or  forty  minutes. 

A  complete  apparatus  for  sterilising,  with  feeding-bottles,  as  devised 
by  Professor  Soxhlet  of  Munich,  can  be  obtained  in  the  market,  but 
by  following  the  above  directions  the  desired  object  Avill  be  satis- 
factorily attained.  There  is  in  my  opinion  no  objection  to  boiled  milk 
other  than  its  taste  which  to  many  children  accustomed  to  unboiled 
milk  is  somewhat  repellent.  With  most  young  infants,  however,  this 
point  is  inconsiderable.  The  scum  is  thicker  and  more  coherent  than 
that  which  forms  on  milk  steamed  for  an  equal  time,  a  small  pro- 
portion of  the  albumen  being  thereby  coagulated  and  lost,  but  from  my 


INFANTILE   WASTING.  I  5 

experience  at  the  hospital  fox  children  where  boiled  milk  is  always  used, 
and  from  knowledge  of  many  infants  reared  entirely  in  this  manner, 
I  helieve  that  boiled  milk  is  practically  as  nutritions  as  fresh  milk  and 
at  least  equally  digestible.  Steam-sterilised  milk,  when  used  at  once,  has, 
I  think,  no  drawback  at  all,  and,  judging  from  some  samples  I  have  tasted 
after  being  kept  for  some  months,  is  nearly  if  not  quite  as  palatable  as 
fresh  milk.  When  it  is  kept  long  in  bottles  the  cream  separates  in 
large  masses,  but  all  that  is  requisite  then  before  using  it  is  to  thoroughly 
shake  or  whip  it  up  in  order  to  diffuse  the  cream.  More  prolonged  and 
repeated  sterilisation  is  necessary  when  the  milk  is  to  be  kept  for  an 
indefinite  time,  and  this,  in  our  lack  of  complete  knowledge  of  the 
possible  changes  induced  by  such  a  process,  is  a  point  in  favour  of 
sterilising  milk  at  home  for  daily  use  as  above  recommended.  All  things 
considered,  however,  it  would  seem  that  an  abundant  and  cheap  supply, 
under  effective  supervision,  of  thoroughly  good  milk  in  a  sterilised  form 
would  he  a  great  national  boon,  for  although  boiling  is  effective  for 
sterilisation,  there  is  in  the  houses  of  the  poor  much  risk  of  fresh  con- 
tamination, and  there  is  no  practicable  guarantee  of  the  proper  quality 
of  the  milk  supplied  to  the  masses. 

Before  leaving  this  subject  I  would  shortly  notice  the  allegations 
of  some  that  boiled  or  otherwise  sterilised  milk  is  lacking  in  the  anti- 
scorbutic qualities  of  fresh  milk.  In  answer  to  those  who  quote  isolated 
eases  with  scorbutic  symptoms  which  have  disappeared  when  fresh  milk 
was  substituted  for  sterilised  I  instance,  besides  the  prevalent  and 
increasing  experience  in  all  countries  of  the  apparently  harmless  use 
of  boiled  or  steam-sterilised  milk  in  both  hospitals  and  private  families, 
the  following  evidence  kindly  supplied  me  by  men  who  have  had  much 
greater  personal  experience  of  infants  exclusively  reared  on  such  milk 
than  any  English  physician  can  probably  claim.  Dr.  Emmett  Holt  of 
New  York  has  observed  during  the  past  three  or  four  years  large  numbers 
of  normal  infants  at  several  institutions  who  were  thus  fed,  many  of 
them  being  under  notice  until  they  were  three  years  old  or  over,  as 
well  as  several  others  under  a  similar  regime  during  a  hospital  residence 
of  three  months.  Dr.  Holt  informs  me  that  in  all  his  experience  of  the 
last  eight  years  at  least  he  has  met  Avith  only  two  marked  cases  of  scorbutus, 
the  one  in  a  hospital  infant  who  from  inability  to  digest  milk  in  any 
form  was  kept  exclusively  on  a  malted  food  for  over  three  months,  the 
other  in  an  infant  seen  in  private  practice  who  had  been  fed  from  birth 
on  condensed  milk  and  on  a  malted  food  of  a  brand  highly  approved  and 
widely  used  in  England  and  elsewhere.  He  adds  that  in  his  experience 
and  that  of  other  physicians  in  New  York  scorbutus  is  a  very  rare 
disease,  while  the  practice  of  sterilising  milk  apart  from  cases  in  hospitals 
is  well-nigh  universal  among  well-to-do  people.     I  have  been  informed 


I  6        DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

also  by  Dr.  Glaevecke,  of  the  University  of  Kiel,  that,  while  there  is  a 
very  widespread  use  in  Germany  of  boiled  and  steam-sterilised  milk  in 
hospitals  and  asylums  for  infants  as  well  as  in  the  families  of  both  the 
well-to-do  and  the  labouring  classes,  he  has  never  seen  a  case  of  infantile 
scorbutus  and  that  this  disease  is  extremely  rare  altogether  in  Germany. 
He  adds  that,  in  his  experience,  since  the  use  of  sterilised  milk  has 
become  so  common,  cases  of  thrush  (Soor)  have  greatly  diminished  in 
frequency  and  severity. 

To  render  cow's  milk  sufficiently  alkaline  the  addition  of  lime-water 
is  the  best  method.  For  this  purpose  about  one  and  a  half  or  two 
teaspoonfuls  to  a  pint  of  milk  is  enough. 

I  believe  that  in  a  very  large  number  of  cases  healthy  children  can  be 
reared  successfully  from  the  first  on  the  principles  above  sketched,  but 
doubtless  there  are  many  instances,  especially  in  weakly  infants  and 
those  who  have  been  brought  very  low  by  bad  attempts  at  artificial 
nourishment,  where  a  more  accurate  adaptation  of  cow's  milk  to  infantile 
requirements  is  necessary  and  should  always  be  tried  before  recourse  to 
any  substitution-diet.  I  would,  however,  once  more  emphasise  here  that 
the  commercial  abstraction  of  cream  from  milk,  so  commonly  practised 
to  a  greater  or  less  degree,  is  to  be  credited  with  a  considerable  propor- 
tion of  the  alleged  nutritive  failures  of  cow's  milk.  This  is  probably 
evidenced  by  the  frequent  and  rapid  recovery  in  hospital  practice  of 
much- wasted  infants,  treated  by  good  cow's  milk  alone,  who  had  never- 
theless been  previously  well  cared  for  and  fed  on  milk  according  to 
proper  instructions. 

It  is  owing  to  the  frequent  failure  of  cow's  milk,  given  more  or  less  in 
accordance  with  the  above  directions  whether  with  or  without  lime-  or 
barley-water,  to  agree  with  or  nourish  a  child  that  condensed  milk  and 
a  host  of  patent  and  other  foods  invite  the  attention  of  the  physician  and 
the  public.  I  have  now  for  a  long  time  almost  entirely  discontinued  the 
use,  in  the  case  of  young  infants,  of  such  proffered  aids  after  many  past 
trials.  Doubtless  some  babies  thrive  well  on  condensed  milk  or  on  per- 
haps any  of  the  more  carefully  prepared  predigested  or  malted  farinaceous 
foods,  and  a  few  indeed  appear  to  thrive  on  one  or  other  of  the  worst  and 
most  widely  advertised  articles  in  the  medical  market.  The  abundant 
professional  testimony,  therefore,  which  favours  these  preparations  and 
causes  them  to  exist  and  endure,  is  not  perhaps  to  be  credited  wholly  to 
the  commercial  spirit,  but  partly  to  that  uncritical  experience  which  is 
always  so  shy  of  the  " instantia  negativa"  in  scientific  evidence. 

Absolutely  no  sound  result  can  be  attained  by  the  "trial"  of  such 
foods  on  any  scale  at  hospitals  for  children,  for  the  clinical  material  is  too 
complicated  and  fluctuating,  and  individual  differences  too  great,  for  any 
true  comparison  to  be  made.     Very  many  of  these  foods  are  certainly 


INFANTILE  WASTING.  1  7 

well  taken  by  many  children  over  seven  or  eight  months  old  when  the 
organism  is  becoming  ready  to  deal  with  other  than  a  milk  diet ;  but  the 
elaboration  of  these  manufactures  is  then  proportionally  unnecessary, 
or  may  be  to  some  extent  objectionable,  as  tending  to  diminish  natural 
function  by  anticipating  it.  It  must  be  remembered  that  these  prepara- 
tions must  really  be  criticised  as  the  first  diet  of  infants.  The  only 
practical,  as  the  only  logical  proof  of  the  value  of  such  foods,  would  be 
that  they  satisfactorily  nourish  the  youngest  infants  who  fail  to  respond 
to  their  natural  food  or  the  closest  possible  imitation  of  it.  The  main 
objections  to  these  articles  are  admirably  summarised  by  Dr.  Eotch  in  his 
article  on  "  Infant  Feeding,"  above  quoted,  and,  since  his  positive  advice 
on  this  subject  is  no  less  to  the  point  than  his  criticism,  I  shall  add  here 
a  short  abstract  of  his  conclusions.  There  is  no  guarantee,  says  Dr. 
Rotch  in  effect,  that  even  if  the  published  analysis  be  genuine  the  sub- 
sequent preparation  shall  correspond  to  the  samples,  and  there  is  every 
inducement  to  the  contrary.  In  many  cases  the  foods  are  demonstrably 
not  what  they  claim  to  be,  the  analysis  which  takes  the  physician's  fancy 
being  usually  made  regardless  of  the  ultimately  necessary  dilution,  so  that 
what  enters  the  child's  stomach  is  not  correspondent  to  the  concept  of  it 
in  the  medical  mind.  The  addition  of  starch,  even  if  changed,  as  alleged, 
into  glucose,  is  not  only  unnecessary,  as  the  sugar  might  be  added  from 
the  first,  but  also  generally  erroneous,  as  the  natural  sugar  is  that  of  milk 
which  should  be  converted  into  glucose  by  the  natural  functions  hereby 
allowed  to  fall  into  disuse,  and  there  is  a  similar  but  still  greater  objec- 
tion to  the  predigestion  of  albuminoids  by  peptonised  foods  with  healthy 
children,  in  that  their  stomachs  are  capable  of  dealing  efficiently  with 
such  material  and  should  not  be  prevented  from  exercising  their  function. 
This  last  objection,  however,  of  Dr.  Rotch  is  not  applicable  to  the  tem- 
porary use  of  pancreatised  or  peptonised  foods  to  tide  over  a  bad  time 
in  many  cases  of  disordered  digestion  from  various  causes,  but  I  can 
thoroughly  endorse  his  general  criticism,  having  found  that  in  most  cases 
of  simple  atrophy,  and  still  more  with  normal  infants  who  for  different 
reasons  must  be  hand-fed  from  birth,  the  use  of  all  patent  and  pre- 
digested  foods  can  usually  be  dispensed  with,  and  that  substantially  good 
results  are  but  seldom  obtained  with  them  as  compared  with  the  simpler 
methods  above  indicated. 

Of  condensed  milk  I  would  say,  again  in  accordance  with  Dr.  Rotch 
and  others,  that  it  is  often  very  useful,  especially  for  the  children  of 
the  poor  who  are  mostly  unable  to  obtain  or  properly  adapt  a  sufficiency 
of  good  fresh  milk.  It  is  tolerably  uniform,  conveniently  portable  and 
easily  digestible  when  duly  diluted  with  about  twelve  to  fifteen  or  more 
parts  of  water.  But  as  a  food  it  is  largely  deficient  in  fat  from  its 
original  composition  and  in  solids  generally  from  its  necessary  dilution, 

B 


I  8         DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

and  there  is  often  an  undue  excess  of  cane-sugar.  The  deficiency  of  fatr 
however,  can  be  remedied  by  adding  from  one-eighth  to  one-tenth  part 
of  cream  to  the  diluted  milk.  Without  this  addition  some  children  will 
apparently  thrive  for  a  while,  but  most  will  soon  fail,  and  some  plainly 
waste.  Healthy  infants  fed  from  the  first  on  condensed  milk  and 
digesting  it,  often  seem  to  grow  even  fatter  than  suckled  ones,  but  their 
fat  vanishes  rapidly  under  feverish  and  other  morbid  conditions.  It  is 
further  believed  by  many,  on  apparently  good  grounds,  that  condensed 
and,  still  more,  desiccated  milk-foods  are  deficient  in  whatever  confers 
upon  fresh  milk  its  well-known  antiscorbutic  quality.  Some  evidence 
of  varying  degrees  of  probably  scorbutic  symptoms  in  infants  thus  fed 
has  been  given  by  Dr.  Cheadle,  and  since  his  first  publication  on  this 
subject  I  have  from  time  to  time  met  with  infants  deprived  of  fresh 
milk  and  fed  either  on  farina  or  in  a  few  instances  on  condensed  milk 
alone  who  suffered  from  ulcerated  gums  and  wasting,  but  soon  recovered 
when  their  diet  was  duly  regulated. 

Once  more  I  quote  from  Dr.  Rotch  in  brief  the  directions  for  the 
preparation  of  what  appears  to  me  one  of  the  best  substitutes  for 
mother's  milk,  the  result  of  the  researches  and  practice  of  Dr.  Meigs 
and  himself.  The  ingredients  in  eight  parts  are  milk  one  part,  cream 
two  parts,  sugar-water  (of  the  strength  of  1 8  drachms  of  milk-sugar  to 
one  pint  of  water)  three  parts,  the  remaining  two  parts  consisting  of  a 
mixture  of  plain  water  and  lime-water  in  the  relative  proportions  of 
three  to  one.  The  mixture  shordd  be  made  (with  the  exception  of  the 
lime-water)  as  soon  as  the  milk  and  cream  are  received,  and  then  boiled 
or  steamed  in  a  sterilising  apparatus,  the  lime-water  being  added  after 
the  mixture,  carefully  stoppered  with  cotton  wool,  has  partially  cooled. 
The  food  should  be  prepared  in  one  or  two  quantities  for  the  daily  use, 
and  should  be  kept  similarly  stoppered  in  a  cool  place  or  on  ice.  In 
default  of  success  with  the  rougher  method  at  first  mentioned  this  plan  is 
to  be  highly  recommended.  Another  method  of  adapting  milk  to  weak 
digestions  is  the  preparation  of  what  is  known  as  artificial  human  milk. 
The  cream  is  first  skimmed  off,  and  the  milk  then  divided  into  two  equal 
parts.  From  one  half  the  casein  is  removed  by  rennet,  and  the  result- 
ing whey  and  the  whole  of  the  cream  are  added  to  the  other  half.  Dr. 
Cheadle  urges  that  this  should  never  be  kept  long  for  fear  of  clotting, 
and  should  as  a  rule  be  made  at  home. 

In  dealing  thus  with  the  subject  of  artificial  feeding  the  most  impor- 
tant part  of  the  therapeutics  of  simple  atrophy  has  been  covered.  Just 
as  it  is  necessary  with  a  healthy  child  to  decrease  gradually  the  dilution 
of  the  milk,  so  in  atrophic  cases  Ave  must  often  begin  with  children  of 
several  months  old  as  with  a  normal  infant  at  birth,  with  subsequent 
modifications   according   to   progress.     The   healthy  infant   should   be 


INFANTILE  WASTING.  I  9 

suckled  or  fed  as  aljove  described  for  at  least  nine  months  as  a  rule, 
but  here  the  law  is  not  rigid,  many  thriving  well  for  a  year  without 
any  change  and  others  doing  better  with  earlier  additions  to  their  diet. 
After  this  age  a  certain  proportion  of  farinaceous  food  and  meat-juice 
should  be  given,  but  as  my  subject  is  disease  I  cannot  here  describe 
appropriate  diets  for  advancing  childhood.  Such  details  find  place  in 
special  works,  and  notably  in  the  practical  book  of  Dr.  Eustace  Smith 
on  the  "  Wasting  Diseases  of  Children."  The  great  importance  of  a 
free  supply  of  fat  in  some  form  in  the  food  of  early  childhood  cannot  be 
too  much  insisted  on,  especially  in  view  of  the  fact  that  most  young 
children  object  to  the  fat  of  meat,  which  it  is  useless  to  force  upon  them, 
and  of  the  great  likelihood  that  the  deprivation  of  fatty  food  is  largely 
contributory  to  the  production  of  rickets.  It  is  probable  that  the  fat 
necessary  for  general  tissue-formation  must  be  supplied  as  such  from 
without,  and  hence  when  ordinary  animal  fats  are  refused  cream  or 
butter  should  be  supplied.  Cod-liver  oil  is  specially  useful  to  the 
children  of  the  poor.  Many  such  show  failure  in  nutrition  without  any 
digestive  disturbance,  and  rapidly  improve  when  cod-liver  oil  is  added 
to  their  diet. 

Of  the  various  disorders  of  digestion  from  improper  feeding  which 
cause  continued  wasting  and  are  evidenced  by  obstinate  gastric  and 
intestinal  disturbances  I  shall  subsequently  treat  more  in  detail.  Suffice 
it  to  say  here  that  in  hospital  practice  especially,  as  well  instanced  in  my 
experience  of  the  poor  working  population  of  the  East  of  London,  there 
are  numerous  children  with  no  definite  disease  who  either  from  mere 
half -starvation  or,  what  amounts  to  the  same  thing  or  worse,  from  sharing 
their  parents'  diet,  "  eating  anything,"  are  quite  unable  to  digest  milk. 
In  such  cases  it  is  often  quite  useless  to  give  either  medicines  or  even 
artificial  digestives  with  milk,  although  sometimes  from  the  latter  class 
of  substances  considerable  help  can  be  derived.  Pancreatised  milk,  for 
instance,  may  be  usefully  given  for  a  time,  and  the  child  thus  nourished 
while  its  organs  are  recovering  from  previous  ill-treatment.  But  it  is 
sometimes  necessary  to  give  almost  absolute  rest  to  the  stomach  for  a 
period  Avhich,  however,  must  be  but  short.  In  such  cases  we  order  whey 
and  water  or  whey  and  barley-water  in  equal  parts  or  some  liquid  pre- 
paration of  meat,  such  as  veal-broth  or  weak  beef-tea,  with  a  few  drops, 
frequently  repeated,  of  brandy.  There  is  no  advantage  in  this  temporary 
diet  other  than  that  of  securing  gastric  rest  and  slight  stimulation  to  the 
organism,  and  it  must  not  be  continued  longer  than  a  few  days.  Infants 
who  are  fed  for  several  days  in  this  manner  make  no  progress  in  nutrition, 
and  are  very  apt  to  suffer  from  oedema  of  the  lower  extremities  owing 
in  all  probability  to  the  anaemia  of  partial  starvation.  An  attempt  there- 
fore at  return  to  a  duly  directed  milk  diet,  at  first  perhaps  wholly  or 


20         DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

partially  pancreatised,  must  be  soon  made,  and  made  again  after  each 
intermission. 

In  the  case  of  children  who  remain  unable  to  digest  milk  in  any  form 
or  in  any  quantity  adequate  for  nutrition,  as  shown  by  persistent  vomit- 
ing with  or  without  diarrhoea  and  by  marked  wasting,  we  must  sub- 
stitute for  the  whole  or  a  part  of  the  milk  some  other  diet  containing 
due  proportions  of  the  essential  elements.  Such  a  diet  may  be  supplied 
by  varying  proportions  of  cooked  farina,  such  as  bread-jelly  or  some  kind 
of  malted  flour,  of  raw  meat-juice,  and  of  cream.  In  the  absence  of 
milk  fresh  meat-juice,  containing,  as  it  does,  the  necessary  proteids  and 
salts,  is  absolutely  necessary  as  an  antiscorbutic,  for  young  infants  can- 
not take  fresh  vegetables.  I  have  frequently  found  that  babies  who 
could  not  digest  milk  do  very  well  for  a  short  time  on  a  mixture  of  raw 
meat- juice  with  some  form  of  malted  farina  and  a  little  sugar,  cod-liver 
oil  being  given  in  small  quantities  to  supply  the  necessary  fat.  As  an 
excellent  formula  for  the  basis  of  a  complete  but  temporary  substitution- 
diet  for  milk  I  would  mention  Dr.  Cheadle's  combination  of  bread-jelly, 
raw  meat-juice,  cream  and  sugar,  the  proportion  of  the  meat-juice  being 
that  suitable  to  a  weakly  infant,  and  to  be  raised  gradually  to  double  as 
digestive  power  increases.  The  bread-jelly  is  prepared  by  soaking  in 
cold  water  for  six  or  eight  hours  four  ounces  of  stale  bread,  made  prefer- 
ably of  "  seconds  "  flour.  After  being  well  squeezed  the  pulp  is  boiled 
in  fresh  water  for  an  hour  and  a  half,  strained  and  rubbed  through  a 
fine  hair  sieve,  and  allowed  to  cool  into  a  jelly.  A  tablespoonful  of  the 
jelly  is  to  be  mixed  with  eight  ounces  of  warm  water  previously  boiled. 
To  five  teaspoon  fuls  of  the  solution  six  teaspoonfuls  of  raAv  meat-juice, 
two  teaspoonfuls  of  cream  and  about  half  a  teaspoonful  of  white  sugar 
are  added.  Both  the  jelly  and  the  raw  meat-juice  must  be  prepared 
twice  in  the  twenty-four  hours,  the  cream  taken  in  night  and  morning, 
and  the  meat-juice  must  not  be  added  to  the  food  when  hot.  From  two 
to  three  ounces  of  raw  meat-juice  may  thus  be  given  in  the  twenty-four 
hours.  The  meat-juice  is  prepared  by  finely  mincing  the  best  rump- 
steak  and  adding  one  part  of  cold  water  to  four  of  the  meat,  and  the 
mixture  should  be  stirred  and  left  to  soak  for  half  an  hour.  The  juice 
should  then  be  forcibly  expressed  by  twisting  through  muslin. 

As  an  intermediate  diet  between  milk  and  the  above  about  three 
tablespoonfuls  of  milk  either  pancreatised  or  not  may  be  added  to  the 
bread-jelly  solution  instead  of  the  six  teaspoonfuls  of  meat-juice. 

The  constipation  sometimes  seen  in  wasting  infants  may  be  often 
successfully  treated  by  frequent  and  long-continued  kneading  of  the 
abdomen  with  the  oiled  hand ;  by  small  enemata  of  warm  water  or 
soap  and  water,  or  containing  a  drachm  or  two  of  castor  oil ;  or  with 
a  few  drops  of  castor  oil,  occasionally  repeated,  by  the  mouth.     Other 


AFFECTIONS  OK  THE  Mul.TH.  2  1 

drugs,  such  as  senna,  -aloes,  or  cascara  may  be  tried.  As  soon  as  a  proper 
diet  is  well  taken  this  medication  may  almost  always  be  discontinued. 

Colic  and  flatulence  as  evidenced  by  the  signs  of  abdominal  pain,  and 
also  vomiting  may  often  disappear  with  regulated  diet.  These  symptoms 
are  usually  much  relieved  by  bicarbonate  of  soda  with  syrup  of  ginger 
or  spirit  of  chloroform.  Bismuth,  too,  may  be  given  with  good  effect, 
peppermint-,  caraway-,  or  cinnamon-water  being  a  useful  excipient. 

Diarrlxoza  is  to  be  treated  at  first  in  much  the  same  way.  Like  the 
other  symptoms,  unless  it  be  chronic,  or  marked  intestinal  catarrh  have 
been  set  up,  or  there  be  any  undiscovered  and  independent  disorder,  it 
will  often  subside  with  proper  diet.  While  undigested  food  is  passing 
away  in  the  motions  astringents  are  out  of  place ;  rather  should  we  then 
give  a  purge  or  two  ;  but  when  numerous  fluid  evacuations  of  Avhatever 
nature,  with  or  without  much  mucus,  are  once  established  it  is  always 
desirable,  in  my  opinion,  to  endeavour  to  control  them  according  to  the 
methods  to  be  referred  to  under  the  heading  of  diarrhoea. 

In  cases  of  atrophy,  when  there  is  a  tendency  to  diarrhoea,  cod-liver 
oil,  other  wise  often  so  useful,  should  as  a  general  rule  not  be  given. 


CHAPTER  II. 

AFFECTIONS    OF    THE    MOUTH. 

Dentition. 

The  period  of  eruption  of  the  milk-teeth,  Avhich  lasts  as  a  rule  from 
about  the  sixth  to  the  twenty-fourth  month,  is  one  of  generally  rapid 
organic  advance.  The  glandular  and  higher  nervous  organs  show  at  this 
time  an  especially  active  development  in  strong  contrast  to  their  con- 
dition in  the  first  few  months  of  life.  Such  a  period  is  therefore  liable 
to  be  accompanied  by  disturbances  in  predisposed  children.  Controversy 
is  abundant  as  to  whether  any  or  all  of  such  disturbances  are  caused  by 
or  merely  coincident  with  the  process  of  dentition,  but  the  discussion 
appears  to  be  but  scholastic  or  at  best  unpractical.  A  large  number  of 
children,  indeed  a  great  majority  of  healthy  sucklings,  cut  their  teeth 
without  sign  of  trouble,  and  there  are  thus  no  symptoms  exclusively 
consequent  on  dentition.  On  the  other  hand,  many  infants,  esjjecially 
weakly  ones,  suffer  from  marked  but  irregular  pyrexia  coincident  with 
the  eruption  of  some  or  all  of  their  teeth  and  disappearing  with  the 
accomplishment   of  that   process.      It  is  my   opinion,   based   on  much 


2  2         DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

observation  and  carefully-noted  hospital  cases,  that  this  pyrexia  occasioned 
by  the  local  irritation  is  often  the  only  morbid  symptom.  The  child 
may  be  restless  but  does  not  seem  very  ill,  and  recovery  is  rapid  and 
complete.  The  temperature  may  rise  to  1030  or  104°  F.  Frequently 
there  are  obvious  signs  of  local  irritation  in  redness  and  swelling  of  the 
gum,  sometimes  ulceration,  and  occasionally  aphthous  stomatitis.  It 
seems  useless  to  attempt  to  classify  these  cases  further,  or  to  discuss  how 
far  slight  restlessness  and  pyrexia  during  the  cutting  of  a  tooth  is  to  be 
regarded  as  literally  pathological.  "We  have  no  reason  to  ascribe  to  denti- 
tion as  a  cause  any  of  the  more  widespread  disturbances  of  the  organism 
which  must  frequently  coincide  with  it,  for  when  such  affections  occur 
they  are  as  a  rule  easily  referable  to  other  sources.  The  hypothesis  of 
the  causation  of  otitis  and  of  several  nervous  or  other  phenomena  by 
reflex  irritation  from  the  dental  branch  of  the  fifth  nerve  is  as  gratuitous 
as  it  is  at  first  sight  plausible,  for  such  phenomena  are  frequent  enough 
in  infancy  without  any  dental  irritation  at  all.  Such  simple  applications 
of  the  anatomical  primer  have  often  in  medical  literature  the  credit  of 
scientific  acumen. 

The  gastric  and  intestinal  derangements,  such  as  vomiting  and  diarrhoea, 
■occur  mostly  in  artificially-reared  infants,  and  the  convulsive  attacks  so 
often  set  down  to  dentition  are  nearly  always  attributable  to  rickets  or 
some  ulterior  diathetic  condition.  All  the  pulmonary  and  cutaneous 
troubles  which  are  treated  by  writers  as  due  to  dentition,  either  directly, 
or  indirectly  through  a  liability  to  disorder  induced  by  the  pyrexia,  are 
so  entirely  of  the  same  nature  as  those  which  are  familiar  at  this  age 
apart  from  the  eruption  of  individual  teeth  that  they  may  safely  be 
regarded  as  not  causally  connected  with  teething.  The  practical  lesson 
to  be  learned  from  the  study  of  disorders  which  accompany  or  seem  to 
result  from  dentition  is — never  to  make  the  diagnosis  of  "  teething  "  until 
after  a  most  exhaustive  examination  and  inquiry  and  never  to  be  satisfied 
with  it  before  the  child  is  well.  I  have  said  that  I  believe  considerable 
pyrexia  may  result  from  teething  alone,  and  we  may  be  often  right, 
when  we  find  evidence  of  local  irritation,  in  making  this  diagnosis ;  but 
we  must  never  overlook  the  possible  existence  of  cerebral,  pulmonary, 
intestinal,  faucial  or  other  disorders,  and  should  carefully  watch  for  their 
signs  and  symptoms. 

I  have  never  seen  any  benefit,  local  or  remote,  from  lancing  the  gums, 
except  in  cases  where  hypersemic  tension  was  great,  and  Avould  recom- 
mend that  pyrexia,  gastro-intestinal  trouble,  and  all  other  ailments  which 
may  be  coincident  with  dental  eruptions  should  always  be  treated  on 
their  own  merits,  and  that  medicine  should  not  be  given  unless  indicated 
otherwise  than  by  the  supposed  cause  of  "teething."  The  disorders 
which  are  frequently  thus  named  are  temporary  and  insignificant,  and 


AFFECTIONS  OF  THE  MOUTH.  23 

thus  have  an  appearance  of  yielding  to  almost  any  remedy.  No  better 
instance  of  the  inconsequent  reasoning  of  some  therapeutists  can  he 
found  than  in  the  constantly  recurring  statements  in  journals  of  attacks 
of  convulsions,  sickness,  pyrexia,  abdominal  pain,  or  of  numerous  other 
symptoms  disappearing  with  marvellous  certainty  after  a  few  days'  use  of 
purges,  or  other  drugs  of  widely  different  or  negative  properties. 

While  any  symptom  of  illness  exists  in  an  infant  let  us  beware  of 
basing  our  prognosis  on  the  agreeable  hypothesis  of  dental  causation, 
which  is  a  rife  cause  of  bad  blundering.  I  have  three  times  seen  cases 
of  meningitis  which  had  been  positively  pronounced,  even  after  several 
•days'  observation,  to  be  merely  disorders  of  teething.  It  need  scarcely 
be  said  that  a  medical  reputation  is  sorely  damaged  by  thus  mistaking  the 
early  irritable,  restless,  and  whining  stage  of  brain  disease. 

Stomatitis. 

Ulceration  of  the  mucosa  of  the  mouth  is  of  very  common  occur- 
rence in  children,  especially  in  the  poorer  classes.  There  are  certain 
appearances  besides  the  usually  well-known  redness  and  dryness  of 
the  buccal  mucosa  in  young  infants  which  are  familiar  to  those  who 
have  experience  with  children,  but  are  sometimes  liable  to  be  mis- 
taken as  morbid.  Henoch  has  rightly  drawn  attention  to  certain  small 
yellowish-white  patches  with  a  red  border  which  are  often  seen  sym- 
metrically placed  on  either  side  of  the  palate  just  behind  the  alveolar 
arch  of  the  jaw,  and  may  readily  bleed  when  touched.  They  occur 
in  healthy  children  and  are  sometimes  erroneously  called  syphilitic. 
Henoch's  explanation  that  they  are  due  to  friction  with  the  tongue  in 
sucking  seems  to  be  right.  He  states  that  in  badly-nourished  children 
they  may  occasionally  and  even  deeply  ulcerate.  They  usually  disap- 
pear of  themselves,  but  should  they  spread  they  should  be  locally 
treated  by  touching  with  a  solution  of  zinc  sulphate  or  silver  nitrate. 
The  various  common  kinds  of  stomatitis  may  be  classed  as  follows  : — 

1.  Aphthous.1 — This  occurs  very  frequently  in  infants  in  the  form 
of  small  gray  or  yellowish  papules  or  perhaps  vesicles  situated  anywhere 
on  the  buccal  mucous  membrane,  but  generally  first  observed  inside  the 
lower  lip  and  at  the  tip  and  edges  of  the  tongue.  They  rupture  or  be- 
come flat,  and  a  superficial  small  round  ulcer  appears.  In  a  large  number 
of  cases  occurring  in  apparently  healthy  children  these  little  ulcers  give 

1  It  is  well  to  confine  the  term  aphthce  to  this  form  of  initially  discrete  ulcera- 
tion of  the  buccal  mucosa,  in  accordance  with  most  authorities  here  and  abroad. 
Others  use  the  term  as  synonymous  with  "thrush."  There  is  no  special  fitness  in 
the  word  for  denoting  either  of  these  different  affections,  for  it  was  used  originally 
by  Hippokrates  to  mark,  from  its  meaning  of  "kindling,"  the  fiery  inflammation  of 
erysipelas  or  sacer  ignis. 


24         DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

no  trouble  other  than  a  local  soreness,  and  rapidly  disappear  without 
treatment.  They  are  in  all  probability  due  to  a  germ  from  decomposing 
food,  though  there  is  no  positive  evidence  on  this  point.  Occasionally 
several  members  of  one  family  may  be  affected.  Not  seldom  aphthous 
stomatitis  runs  a  more  severe  course,  especially  in  weakly  children  who 
are  suffering  from  alimentary  trouble  and  appear  to  afford  a  special  nidus 
for  the  disorder.  The  ulcers  may  spread  and  become  confluent,  covering 
almost  the  whole  buccal  cavity,  and  there  may  be  swelling  of  the  sub- 
maxillary glands  and  of  the  face  with  considerable  rise  of  temperature. 
The  breath  is  foul  and  the  saliva  profuse.  In  these  cases  it  is  plain  that 
the  general  condition  must  attract  our  main  attention,  for  this  underlies 
the  severity  of  the  buccal  ulceration.  But  the  local  discomfort  is  great, 
and  the  pain  felt  on  touching  the  ulcers,  especially  on  the  tongue,  is 
often  so  severe  as  to  interfere  much  with  feeding.  This  should  be 
treated  by  the  application  of  salol  or  borax  and  glycerine,  and  by 
chlorate  of  potash  in  small  doses  given  internally  for  a  short  time.  This 
latter  drug  should  not,  in  my  opinion,  be  omitted,  comparatively  slight 
though  its  modern  credit  may  be.  The  local  use  of  it  as  a  mouth 
wash  is  not  equally  effective.  In  extensive  ulceration  the  application  of 
nitrate  of  silver  may  be  found  necessary. 

The  practical  import  of  this  affection  may  be  gathered  from  the  general 
condition  of  the  child.  It  is  insignificant  per  se,  but  when  obstinate 
and  spreading  in  a  case  of  severe  illness  it  is  one  more  indication  of  the 
gravity  of  the  case. 

2.  Ulcerative  Stomatitis  or  Stomacace. — This  is  a  very  common  form 
of  mouth-disease,  especially  in  hospital  patients.  It  begins  as  a  rule  in 
the  gums,  which  are  at  first  red,  swollen,  and  spongy,  bleeding  readily, 
and  soon  afterwards  take  on  a  yellowish-grey  ulcerated  surface.  This 
ulceration  may  be  temporary,  or  may  spread  and  endure  for  weeks  or 
more.  The  breath  is  foul,  the  saliva  abundant  and  often  bloody,  and 
there  is  pain  with  all  movements  of  the  mouth.  The  teeth  may  become 
loose  and  fall  out,  and  the  ulceration  frequently  spreads  to  the  lips  and 
cheek  and  to  the  tongue  where  it  is  in  contact  with  the  gums  or  lining 
of  the  mouth.  The  ulcerated  patches  are  of  various  size,  and  sometimes 
very  extensive.  The  glands  beneath  the  jaw  are  tender  and  swollen, 
and  there  is  more  or  less  pyrexia. 

This  disorder,  whether  slight  or  severe,  is  most  common  in  children 
over  two  years  old,  and  is  probably  the  result  of  bad  nutrition  or  a  bad 
constitution,  or  both  combined.  It  is  seen  in  rickets  and  tuberculosis, 
has  been  observed  in  connection  with  congenital  heart  disease,  and  is 
doubtless  due  in  some  cases  to  a  scorbutic  condition.  There  is,  how- 
ever, as  far  as  I  have  observed,  no  essential  difference  between  the  most 
severe  cases  of  ulcerative  stomatitis  which  are  certainly  not  scorbutic,  as 


AFFECTIONS  OF  THE  MOUTH.  2$ 

far  as  their  history  can  tell  us,  and  those  far  Less  frequent  ones  whose 
diet  might  occasion  scurvy.  That  scurvy,  however,  may  account  for 
some  cases  of  this  disease  in  children  is  not  to  he  denied;  for  a  history 
of  the  absence  of  milk,  fresh  meat  and  vegetable  food  from  the  dietary 
is  sometimes  clearly  to  be  obtained,  and  more  or  less  marked  instances 
are  sometimes  seen  after  a  diet  of  desiccated  or  even  condensed  milk,  or 
when  antiscorbutic  food  has  been  very  deficient  in  quantity.  Several 
micro-organisms,  some  of  which  have  been  stated  to  be  inoculable,  have 
been  found  in  some  cases  of  ulcerative  stomatitis,  and  these  may  pos- 
sibly be  the  proximate  cause  of  the  affection.  Many  severe  examples 
of  this  malady  are  seen  from  time  to  time  in  epidemics  of  measles, 
the  ulcers  being  frequently  covered  with  a  membranous  exudation  the 
removal  of  which  leaves  a  bleeding  surface.  The  question  of  the  alter- 
native diagnosis  of  diphtheria  may  thus  be  raised,  especially  when  there 
is  concomitant  faucial  inflammation  with  exudation.  Several  cases  of 
this  kind  occurred  in  the  East  of  London  in  the  autumn  of  1890,  many 
showing  also  severe  broncho-pneumonia  and  laryngitis,  but  none  being 
followed  by  the  sequelae  of  diphtheria. 

Dr.  J.  F.  Payne  x  has  made  the  observation  that  a  pustular  eruption 
on  the  lips  and  hands  often  accompanies  ulcerative  stomatitis,  and  most 
aptly  suggests  that  both  eruptions  arise  from  the  same  virus,  the  different 
lesions  being  due  to  their  different  locale. 

The  disease  is  certainly  very  rare  in  children,  however  weakly,  who 
are  properly  fed,  cleaned,  and  cared  for.  I  have  nevertheless  occasionally 
seen  ulceration  and  sloughing  neither  deep  nor  lasting  of  the  mucosa  of 
the  gums  and  cheek  hi  apparently  healthy  and  cleanly  children,  where 
no  cause  could  be  assigned.  It  is  by  no  means  rare  to  see  such  ulcera- 
tion as  the  direct  effect  of  a  jagged  tooth.  In  this  context  may  be  men- 
tioned the  ulcer  near  the  frsenum  lingua?  which  is  observed  in  some 
cases  of  whooping-cough  from  the  friction  of  the  tongue  upon  the  lower 
incisors.  Henoch  attributes  ulcerative  stomatitis  in  some  cases  to  the 
processes  of  the  second  dentition,  but  both  the  proof  and  disproof  of 
this  theory  seem  equally  difficult  to  establish. 

The  discovery  of  diphtheria  as  evidenced  by  pharyngeal  affection  is 
sometimes  preceded  by  that  of  a  stomatitis  which  is  not  easiby  if  at  all 
distinguishable  from  the  simple  disorder.  It  may  be  questioned  whether 
such  stomatitis  be  diphtheritic  in  nature,  or  merely  a  favourable  soil  for 
the  specific  poison. 

Chlorate  of  potash  or  soda,  taken  internally,   appears  generally  to 

control  this  kind  of  stomatitis,  unless  the  bone  be  involved,  and  the 

application  of  salol  in  glycerine,  of  the  strength  of  one  drachm  to  the 

ounce,  to  the  parts  affected  by  means  of  a  brush  is  very  effective,  recovery 

1  St.  Thomas'  Hospital  Reports,  1883. 


26         DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

often  taking  place  with,  great  rapidity.  It  may  be  necessary  in  the 
severer  cases  to  apply  some  astringent,  such  as  alum,  or  a  solution  of 
sulphate  of  zinc  or  sulphate  of  copper  (each  10-12  grains  to  the  ounce), 
or  nitrate  of  silver  (2-5  grains  to  the  ounce),  to  the  ulcerated  surface, 
but  in  many  of  the  milder  instances  careful  cleansing  of  the  mouth  with 
a,  weak  solution  of  permanganate  of  potash  or  some  other  antiseptic  will 
be  all  that  is  required.  In  all  the  numerous  cases  where  there  is 
cachexia  of  any  kind  general  hygienic  and  nutritive  measures  are  in- 
dispensable, the  diet  must  be  specially  attended  to  when  scurvy  is  in 
question,  and  any  co-existent  disease  must  be  expressly  treated.  Bone- 
affection  must  be  dealt  with  by  surgical  measures. 

3.  Gangrenous  Stomatitis  (Noma,  Gancrum  Oris).  —  The  essential 
characters  of  this  disease,  which  has  only  clinical  rank  as  a  separate 
affection,  are  that  the  ulceration  rapidly  becomes  gangrenous,  invades 
the  deeper  tissues  of  the  cheek  or  lips,  perforating  and  destroying  them 
in  their  whole  thickness,  and  mostly  causes  death.  Clinically,  the  first 
usually  observed  symptom  is  swelling  of  the  face,  most  often  of  the 
■cheek,  but  it  may  involve  the  lips  and  chin  and  the  lower  eyelid.  The 
most  marked  part  of  the  swelling  is  found  by  careful  feeling  to  be  hard, 
but  is  generally  neither  tender,  nor,  at  first,  red.  If  the  inside  of  the 
mouth  be  examined  a  gangrenous  ulcer  is  seen,  usually  opposite  the 
hard  part  of  the  swelling,  and  the  breath  is  almost  always  offensively 
foul.  There  is  much  salivation  and  swelling  of  the  neighbouring  glands 
and  of  the  surrounding  connective  tissue.  A  certain  degree  of  pyrexia 
always  exists,  sometimes  very  slight,  sometimes  high  ;  and  although  some 
cases  die  very  early  from  exhaustion  before  perforation  occurs,  others 
linger  on  for  two  or  three  weeks.  Some  seem  to  suffer  no  pain,  and 
even  appear  lively  long  after  extensive  destruction  of  the  face,  including 
the  bones,  has  taken  place.  Before  perforation  the  swelling  becomes 
hard  and  centrally  red  and  shiny,  and  then  turns  black.  Occasionally 
the  whole  process,  from  the  first  observed  symptom  to  perforation,  is  but 
of  a  few  days'  duration.  In  some  fatal  cases  there  is  no  external  lesion 
other  than  swelling,  and  the  patient  dies  from  pulmonary  inflammation 
or  gangrene  owing  to  septic  inhalation  from  the  sloughing  mucosa  of  the 
mouth.  In  one  case  of  mine  death  occurred  thus  after  the  buccal  ulcer 
had  ceased  to  spread  and  had  shown  signs  of  the  healing  process. 

Diarrhoea  has  been  frequently  observed,  attributable  probably  to  the 
swallowing  of  putrid  matter  from  the  ulcer,  and  the  broncho-pneumonia 
which  occurs,  and  is  fatal  in  so  many  instances,  may  be  referred  to  inhala- 
tion of  the  same.  Gangrene  of  the  lung  is  frequently  found  post-mortem. 
The  few  cases  which  recover  suffer  deformity  from  contraction  of  the 
face,  adhesion  of  the  cheek  to  the  jaw,  or  turning  out  of  the  lower 
eyelid. 


AFFECTIONS  OF  THE  MOUTH.  27 

This  disease  has  not  been  proved  to  result  from  the  action  of  a  specific 
germ,  although  cases  have  been  reported  where  micro-organisms  were 
found  in  the  blood  or  tissues.  It  occurs  most  often  in  cachectic  children 
past  infancy,  after  the  exanthemata,  especially  measles  and  less  commonly 
enteric  fever,  and  sometimes  after  affections  of  the  lungs  or  bowels. 
Tubercular  children  are  said  to  be  liable  to  it.  Henoch  quotes  two  cases 
where  noma  seemed  to  arise  out  of  an  ordinary  ulcerative  stomatitis.  I 
have  myself  seen  one  probable  example  of  this,  and  Eustace  Smith  relates 
the  cases  of  a  cachectic  brother  and  sister  suffering  respectively  from  these 
diseases.  Henoch  further  gives  one  case,  which  recovered,  of  gangrenous 
perforation  of  the  cheek,  which  began  as  an  abscess  without  involvement 
of  the  buccal  mucosa.  It  would  thus  appear  that  this  disease  has  no 
{etiological  claim  at  present  to  separate  nosological  rank. 

I  add  an  abstract  of  a  case  of  my  own,  illustrating  this  point  among 
others.  A  boy  of  three  years  old  began  to  have  "  ulcerated  mouth  "  in 
form  of  "  small  blisters  "  six  weeks  before  admission  to  hospital.  Five 
weeks  before  admission  he  had  measles,  and  the  mouth  became  much 
worse.  He  was  found  to  have  marked  bony  signs  of  rickets  on  admission. 
The  mucous  membrane  inside  the  left  angle  of  the  mouth  was  gangrenous, 
and  the  alveolar  ridge  of  the  lower  jaw  was  carious.  Eight  teeth  had 
recently  dropped  out.  The  mucous  membrane  on  the  inner  surface  of 
the  lower  jaw  and  under  the  tongue  Avas  also  gangrenous,  and  there  was 
disgusting  fcetor.  The  glands  under  the  jaw  were  much  enlarged  and 
the  tissues  around  infiltrated,  causing  the  appearance  of  a  huge  double 
chin.  The  child  could  swallow  well.  There  were  no  signs  of  broncho- 
pneumonia. The  diseased  surfaces  were  touched  with  strong  nitric  acid, 
and  chlorate  of  potash  and  iron  given.  Eight  days  after  admission,  the 
child  growing  weaker  and  the  temperature  ranging  from  990  to  102°, 
bronchitic  signs  were  heard,  and  on  the  ninth  day  there  were  signs  of 
consolidation.  There  was  a  slough  as  large  as  a  crown  piece  on  the 
external  and  lower  surface  of  the  left  lower  jaw.  The  child  died  on  the 
tenth  day  with  a  temperature  of  106°. 

To  prevent,  if  it  be  ever  possible  to  prevent  by  art,  the  usually  fatal 
issue,  the  parts  involved  should  be  actively  treated  by  cautery  or  exci- 
sion as  soon  as  observed.  Literature  records  but  few  recoveries,  and 
fewer,  if  any,  cures.  My  own  few  cases,  but  five  or  six  in  all,  have 
been  fatal,  although  locally  treated,  but  none  were  seen  in  the  earliest 
stage.  Before  the  ulceration  has  involved  the  deeper  tissues  some  hope 
may  be  entertained  of  arresting  it.  Ordinary  caustics  are  probably 
useless.     Henoch  recommends  the  thermo-cautery. 

In  the  following  case  of  a  boy,  set.  3^,  admitted  with  enteric  fever, 
local  treatment  of  the  disease  by  strong  nitric  acid  seems  to  have  had 
some  good  effect,  although  the  child  died  from  inflammation  of  the  lungs. 


2  8         DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

On  admission  there  was  increased  salivary  secretion,  the  gums  bled  easily, 
and  the  breath  smelt  very  foul.  Ten  days  subsequently,  rose-spots  still 
existing,  the  left  side  of  the  face  was  found  to  be  swollen  and  red,  and 
the  breath  was  exceedingly  foetid.  A  black  slough  the  size  of  a  shilling 
was  seen  under  the  cheek.  The  child  did  not  seem  in  any  way  worse, 
and  the  temperature  was  ioo°.  Ether  was  administered,  the  slough 
scraped  away  with  a  sharp  spoon,  two  upper  molar  teeth  with  a  necrosed 
piece  of  jaw  were  removed,  and  the  healthy  mucous  membrane  being 
covered  with  oil  the  raw  surface  was  cauterised  with  fuming  nitric 
acid.  On  the  following  day  the  fcetor  had  disappeared,  and  there  was 
no  sign  of  the  disease  spreading.  In  the  evening  pulmonary  symptoms 
came  on,  with  physical  signs  of  bronchitis  only,  and  the  child  died 
at  midnight.  Post-mortem  there  was  no  sign  of  spreading  disease  in 
the  mouth.  There  was  early  broncho-pneumonia  with  incomplete  but 
widely-dispersed  consolidation  of  both  lungs. 

The  parts  should  be  kept  throughout  as  clean  as  possible  by  syringing 
with  washes  of  permanganate  of  potash  or  chlorinated  soda.  Every 
effort  should  be  made,  in  spite  of  the  great  local  difficulties,  to  give 
concentrated  nutriment,  such  as  the  most  approved  preparations  of  meat- 
juice,  at  frequent  intervals,  and  the  patient  should  be  freely  stimulated 
with  alcohol.  It  may  be  necessary  to  feed  the  patient  through  the  nasal 
tube,  or  by  enemata  which,  owing  to  the  absorption  of  their  watery 
vehicle,  are  far  preferable  to  suppositories.  Opium  should  be  given 
when  there  is  pain,  and  I  would  recommend  it  in  all  early  cases  in  view 
of  the  possible  action  of  its  healing  power. 

For  the  sake  of  the  attendants  the  mouth  of  the  patient  should  be 
covered  with  cotton- avooI  or  a  compress  soaked  in  solution  of  thymol 
or  some  other  disinfectant,  and  a  constant  spray  of  carbolic  acid  or 
creasote  should  be  maintained  close  to  the  bed.  The  child  should  be 
kept  as  much  as  possible  in  the  prone  position,  to  lessen  the  swallowing 
and  inhalation  of  the  putrid  discharges. 

My  colleague,  Mr.  L.  A.  Dunn,  recommends,  after  a  preliminary 
tracheotomy,  free  cauterisation  of  the  diseased  surface,  and,  plugging 
the  mouth  antiseptically,  would  treat  it  as  a  closed  cavity,  all  food 
being  given  by  the  nasal  tube. 

4.  Thrush  is  the  name  given  to  an  affection  of  the  mucous  membrane, 
especially  of  the  mouth,  characterised  by  numerous  milk-white  specks 
and  patches  of  various  sizes.  The  mucosa  of  the  mouth  is  dry  and  red 
and  sometimes  painful,  and  the  white  patches  have  a  tendency  to  run 
together,  especially  over  the  palatal  arch.  This  disease  is  due  to  the  pre- 
sence of  a  fungus  which,  formerly  classed  as  an  Oidium  and  allied  with 
the  fungus  of  favus,  is  now  referred  to  the  group  of  yeast  fungi.  The 
growth,   according    to   Plant,    is   characterised  by   abundant  mycelium, 


AFFECTIONS  OF  THE  MOUTH.  29 

produces  fermentation,  and  when  purely  cultivated  causes  distinct  thxuah 

in  the  crop  of  fowls. 

Thrush  in  its  simplest  form  attacks  young  infants,  and  mostly,  if  not 
entirely,  those  who  are  weakly  or  are  artificially  fed.  It  is  not  neces- 
sarily accompanied  by  any  inflammation.  It  may  be  conveyed  by  means 
of  infected  articles,  such  as  bottle-tubes,  but  probably  not  to  a  perfectly 
healthy  mucous  membrane.  In  the  milder  cases  a  regulated  diet  and 
careful  removal  of  the  patches  by  wiping  out  the  mouth  with  some  such 
soft  substance  as  lint  will  quickly  cure  the  disease,  with  or  without  the 
use  of  the  glycerine  of  borax  to  the  parts  involved.  In  many  instances, 
however,  the  affection  is  much  more  severe,  the  fungus  growing  rapidly, 
occupying  the  whole  mouth  and  pharynx,  and  causing  superficial  ulce- 
ration wdiich  is  seen  on  the  forcible  removal  of  the  white  substance. 
For  this  development  there  must  probably  be  antecedent  disorder  of  the 
mucous  membrane  and  an  acid  state  of  the  secretions,  and  there  is  often 
evidence  of  concomitant  derangement  of  the  whole  alimentary  canal. 
Diarrhoea  may  be  marked  and  fatal.  It  is  in  cases  of  wasting  from 
bad  feeding  and  disease  that  this  severe  form  is  usually  or  always  met 
with.  In  adults  thrush  occurs  almost  exclusively  with  extreme  exhaus- 
tion from  disease,  such  as  typhoid  fever  or  phthisis,  and  generally 
warrants  the  gravest  prognosis.  The  fungus  is  found  post-mortem  in 
the  oesophagus  and  stomach,  and  occasionally  in  the  intestine,  but  not 
in  the  ciliated  epithelial  regions  of  the  nose  or  larynx.  Very  frequently 
in  the  graver  cases  there  is  a  red  eruption  from  a  superficial  dermatitis 
spreading  from  the  anus  to  the  nates,  due  to  the  irritation  of  acrid  dis- 
charges from  the  bowel.  This  is  often  seen,  among  other  diseases,  in 
connection  with  congenital  syphilis.  It  is  to  the  antecedent  disorder 
which  favours  the  luxuriant  vegetation  of  the  fungus  that  the  serious 
symptoms  must  be  ascribed,  and  the  extent  of  the  thrush  itself  must  be 
regarded  rather  in  the  light  of  an  index  to  the  gravity  of  such  disorder. 
Even  in  the  mildest  cases  some  decomposition  of  the  food  in  the  mouth 
is  to  be  assumed  as  forming  the  nidus  for  the  fungous  growth. 

The  remains  of  milk  are  sometimes  mistaken  for  thrush  in  the  mouth, 
having  much  the  same  appearance,  but  they  are  readily  removable  when 
touched,  and  microscopical  examination  will  decide  the  diagnosis.  Occa- 
sionally also  a  patch  of  desquamation  of  the  epithelium  of  the  tongue 
may  be  confused  with  thrush  on  superficial  examination.  The  treat- 
ment of  thrush  in  mild  cases  consists  in  removing  the  patches  as  above 
mentioned ;  in  the  more  severe  cases  the  general  condition  calls  first  for 
attention,  but  the  local  trouble  should  be  relieved  by  washing  or  syringing 
the  mouth  with  weak  alkaline  solutions,  such  as  carbonate  of  potash  or 
soda,  or  by  the  use  of  glycerine  of  borax.  In  some  cases  the  application 
of  a  solution  of  nitrate  of  silver  (1-2  grains  to  the  ounce)  to  the  mucous 


30         DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

membrane  of  the  whole  mouth  will  prevent  further  development  of  the 
affection.  In  any  case,  with  especial  regard  to  the  co-existent  stomatitis, 
the  chlorate  of  potash  may  he  given  internally,  or  a  ie^Y  grains  of  borax 
may  be  advantageously  taken  three  or  four  times  a  day.  Strict  clean- 
liness must  be  observed  in  the  feeding-apparatus  of  patients  with  thrush, 
and  starchy  and  saccharine  articles  of  diet  must  be  given  sparingly  or 
not  at  all.     Alcoholic  stimulation  will  be  sometimes  necessary. 


CHAPTER    III. 

AFFECTIONS     OF     THE     FAUCES. 

Acute  Catarrh  of  the  Pharynx. 

Very  young  infants  are  but  little  liable  to  catarrhal  inflammation  of  the 
fauces,  but  sore  throat  from  such  a  cause  is  frequent  after  this  period. 
Some  attacks  begin  with  feverishness  and  evidence  of  soreness  on 
swallowing,  and  may  be  soon  followed  by  nasal  catarrh.  The  pharynx 
is  seen  to  be  red,  the  tonsils  and  faucial  pillars  slightly  swollen,  and  the 
uvula  elongated.  In  other  cases  the  temperature  is  high  from  the  first, 
there  may  be  slight  rigors  or  even  convulsions  or  vomiting,  and  the  child 
may  appear  very  ill  with  furred  tongue,  anorexia  and  headache.  Pain 
in  the  throat  may  not  be  prominent  although  tenderness  may  always  be 
demonstrated  by  pressure  in  the  direction  of  the  tonsils,  and  inspection 
will  show  a  pharyngitis  with  more  or  less  tonsillar  swelling.  Such  an 
affection,  with  or  without  pain,  often  ushers  in  the  exanthemata,  espe- 
cially scarlatina  and  sometimes  enteric  fever  ;  and  this  association  should 
always  be  borne  in  mind  when  we  are  making  our  diagnosis. 

I  would  lay  stress  on  the  absence  of  complaint  or  evidence  of  discom- 
fort about  the  throat  in  many  of  these  cases  in  childhood,  for  omission 
from  this  cause  to  examine  the  fauces  frequently  mystifies  a  case  of 
febrile  nature  which  would  be  otherwise  clear.  Both  these  sets  of  cases 
are  apparently  similar  in  origin,  the  difference  of  symptoms  depending 
probably  on  the  child's  idiosyncrasy,  and  the  affection  usually  passes  off 
in  a  few  days.  The  tonsillar  swelling  may  be  more  or  less  prominent 
than  the  general  inflammatory  condition  of  the  fauces.  Some  at  least 
of  these  cases  seem  to  be  due  to  chill,  but  the  clinical  group  is  probably 
of  no  single  serological  origin. 

Such  cases  as  these  require  but  little  or  no  active  treatment.  Warmth 
and  confinement  to  bed,  with  a  saline  mixture  containing  chlorate  of 
potash,  are  the  best  remedies ;  and  if  there  be  much  pain  or  restlessness  a 


AFFECTIONS  OF  THE  FAUCES.  3  I 

few  grains  of  Dover's  powder,  according  to  ago,  may  well  be  given.  The 
temperature  may  run  high,  as  in  many  other  .slight  disorders  of  childhood, 
but  does  not  require  any  antidotal  treatment.  I  strongly  deprecate  the 
meddling  administrations  of  the  now  fashionable  "antipyretics,"  such  as 
antipyrin  and  aconite,  not  without  past  experience  of  them.  They  are 
never  indicated,  nor,  when  operative,  always  harmless. 

Acute  Tonsillitis. 

Under  this  heading  we  have  again  to  recognise  a  somewhat  hetero- 
geneous class  of  cases  which,  owing  to  the  prominence  of  tonsillar  in- 
flammation from  the  first  and  the  absence  of  general  catarrhal  symptoms, 
deserve  to  be  considered  apart  for  practical  purposes,  although  serologi- 
cally multiform.  Many  cases  are  marked  by  a  tendency  to  recur  and 
by  the  frequent  presence  of  patches  of  whitish  or  yellowish  inspissated 
exudations  on  the  swollen  tonsil.  Pain  and  dysphagia  may  be  great, 
but  on  the  other  hand  are  often  insignificant,  and  the  tonsillitis  is  some- 
times recognised  only  by  inspection  during  the  routine  inquiry  as  to  the 
cause  of  any  given  case  of  feverishness,  or,  it  may  be,  of  but  slight  malaise. 
We  see  tonsillitis  with  all  degrees  of  local  severity  and  constitutional 
disturbance,  and  have  often  to  remark  on  the  apparent  disproportion 
between  acuteness  of  general  symptoms  and  slight  local  discomfort, 
although  severe  tonsillitis  is  always  attended  by  marked  febrile  move- 
ment. Probably  the  affection  is  referable  to  several  causes.  Unhygienic 
surroundings,  such  as  bad  drainage  or  foul  air,  are  often  supposed  to  be 
probable  sources,  and  sometimes  with  apparent  reason,  but  the  affection 
may  arise  suddenly  in  a  seemingly  healthy  child  in  presumably  good 
sanitary  conditions.  As  in  the  adult,  so  perhaps  still  more  in  the  child, 
there  is  a  frequent  connection  between  tonsillitis  and  rheumatism.  Ton- 
sillitis, indeed,  besides  being  a  frequent  accompaniment  of  rheumatic 
fever,  may  sometimes  be  the  first  indication  of  rheumatism  evidenced 
afterwards  by  less  equivocal  signs  of  that  disease.  In  some  instances,  and 
especially  in  older  children,  the  inflammation  rapidly  goes  on  to  suppura- 
tion, and  the  abscess  in  one  or  sometimes  in  both  tonsils  may  burst,  the 
case  ending  then  in  rapid  recovery.  Exactly  the  same  kind  of  tonsillitis, 
whether  exudative  or  suppurative,  is  seen  in  adults,  and  there  is  nothing 
special  in  respect  to  its  clinical  course  in  childhood.  The  frequent 
difficulty  of  diagnosis,  however,  between  exudative  tonsillitis  and  other 
diseases,  especially  incident  on  childhood,  in  which  tonsillitis  plays  a  pro- 
minent part,  renders  this  subject  of  great  importance.  In  practice  we 
often  have  to  decide  whether  a  given  case  of  tonsillitis  is  non-contagious 
or  a  symptom  of  diphtheria  or  scarlatina,  and  all  experienced  practitioners 
know  that  there  are  certain  cases  where  this  diagnostic  question,  even 


32         DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

after  the  most  careful  observation  and  inquiry,  is  at  first  insoluble.  The 
more  or  less  essential  signs  of  scarlatinous  and  diphtheritic  throats  will 
be  dealt  with  in  their  proper  place ;  but  it  must  be  noted  here  that  the 
appearance  of  the  throat  and  tongue  in  many  cases  of  scarlatina  is  but 
slightly  if  at  all  characteristic,  and  that  when  the  bright  redness  of  the 
scarlatinous  pharynx  is  absent  the  swelling  or  patches  of  ulceration  of 
the  tonsils  may  be  almost  or  quite  indistinguishable  from  that  of  the 
independent  affection  we  are  now  considering.  We  must  here  remember 
how  frequently  most  acute  diseases  lack  their  typical  signs,  and  should 
therefore  hesitate  for  a  while  before  positively  excluding  scarlatina  in 
any  case  of  suddenly  occurring  tonsillitis,  especially  when  there  has  been 
vomiting.  The  early  appearance  of  the  rash  in  scarlatina  will  as  a  rule 
soon  remove  doubt,  although  in  some  undoubted  cases  the  scarlatinous 
sore  throat  is  followed  by  no  observed  rash.  With  regard  to  diphtheria 
the  difficulty  is  greater,  of  longer  duration,  and,  apart  from  the  possible 
discovery  of  the  probably  specific  bacillus,  sometimes  insuperable.  There 
are  cases  proved  diphtheritic  by  their  sequel  or  by  their  association  with 
marked  instances  of  the  disease  which  show  but  little  or  no  membranous 
appearance,  no  nasal  symptoms,  and  very  slight,  if  any,  constitutional 
disturbance  ;  while  in  non-diphtheritic  tonsillitis  the  exudation  frequently 
covers  the  tonsils  as  with  a  membrane.  In  most  doubtful  instances  we 
should  wait  for  two  or  three  days  before  pronouncing  on  the  nature  of 
the  case,  by  which  time  the  exudation,  if  it  be  not  diphtheritic,  will 
usually  be  markedly  diminished.  Having  erred  and  seen  many  others 
of  long  experience  err  in  the  too  hasty  diagnosis  of  such  cases  I  would 
emphasise  strongly  the  danger  of  overmuch  confidence  in  typical  descrip- 
tions or  in  one's  own  clinical  acumen.  It  were  better  to  be  confronted 
with  our  mistaken  caution  in  a  case  where  the  sequel,  or  several  subse- 
quent attacks,  may  disprove  diphtheria,  than  to  see  or  hear  of  a  child's 
death  from  heart-failure  or  other  untoward  event  after  we  have  pro- 
nounced the  diagnosis  of  simple  tonsillitis.  The  existence  or  recent 
antecedence  of  scarlatina  or  diphtheria  in  the  house  or  close  neighbour- 
hood of  a  case  in  question  may  give  us  some  diagnostic  aid,  as  also  might 
the  very  rare  possibility  of  excluding  all  likely  sources  of  such  infections. 
The  usual  characteristics  of  this  form  of  tonsillitis  are,  however, 
enough  in  most  instances  to  prevent  much  diagnostic  difficulty,  at  least 
after  a  day  or  two.  There  are  frequently  well-marked  ulcers  at  the  onset 
quite  unlike  diphtheria.  The  white  or  yellow  or  yellowish- white  exuda- 
tion, differing  from  the  greyish  membrane  seen  after  a  few  days  in  most 
diphtheritic  cases,  occurs  at  first  in  small  patches  which  neither  coalesce 
nor  rapidly  spread,  and  leaves  the  soft  palate,  uvula  and  back  of  the 
pharynx  unaffected.  It  usually  occupies,  moreover,  one  tonsil  only,  or 
one  before  the  other. 


AFFECTIONS  OF  THE  FAUCES.  T>5 

Glandular  enlargement  under  the  lower  jaw  does  not  help  us  much 
in  diagnosis,  for  it  frequently  occurs  in  tonsillitis  while  it  may  be  hut 
slight  in  diphtheria,  and  we  must  remember  that  the  typical  "ashen- 
grey"  appearance  of  diphtheritic  membrane  is  not  generally  seen  at  the 
early  time  when  the  diagnostic  question  is  at  once  most  difficult  and 
most  important.  The  constitutional  symptoms  and  fever,  sometimes 
very  high,  are  generally  prominent  in  tonsillitis,  and  there  may  be 
rigors ;  while  in  diphtheria  there  may  be  but  slight  or  no  marked  symp- 
toms of  illness,  and  often  very  little  fever.  The  urine  in  tonsillitis  is 
usually  scanty  and  high-coloured,  and  not  seldom  slightly  albuminous. 

If  we  are  satisfied  as  to  the  non-contagious  nature  of  a  given  case  of 
tonsillitis,  or  at  least  that  it  is  neither  scarlatina  nor  diphtheria,  as  after 
due  experience  and  careful  observation  we  can  perhaps  often  be,  the 
prognosis  may  be  said  to  be  nearly  always  good.  There  is  certainly 
good  reason  to  believe  from  many  recorded  instances  that  there  is  an 
epidemic  form  of  tonsillitis  which  is  neither  scarlet  fever  nor  diphtheria, 
but  the  greatest  caution  is  necessary  before  allowing  this  probability  to 
influence  our  diagnosis  or  prognosis. 

In  the  most  acute  cases  the  temperature  may  rise  as  high  as  1050 
or  more,  and  sometimes  after  five  or  six  days  there  is  a  critical  fall. 
The  affection  very  often  recurs  without  any  apparent  exciting  cause. 
Doubtless  in  some  cases  this  recurrence  causes  chronic  hypertrophy  of 
the  tonsils,  but  on  the  other  hand,  as  we  shall  presently  see,  the  origin 
of  chronic  enlargement  of  the  tonsils  is  often  very  early  and  insidious, 
and  this  condition  induces  a  great  liability  to  acute  attacks.  In  those 
cases  of  non-suppurative  tonsillitis  where  patches  of  whitish  or  yellowish 
exudation  are  seen  the  cpiestion  of  insanitary  conditions  as  a  possible 
cause  must  be  thought  of,  and  the  patients,  if  necessary,  removed,  not 
only  for  their  immediate  good,  but  also  in  view  of  the  undoubted  fact 
that  any  continuing  morbid  condition  of  the  fauces  is  favourable  soil  for 
the  reception  of  the  diphtheritic  poison. 

The  treatment  of  tonsdlitis  is  mainly  symptomatic,  but  there  may  be 
some  causal  indications.  For  the  local  trouble,  hot  poultices  or  com- 
presses frequently  renewed  should  be  applied  to  the  throat,  and  steam 
should  be  inhaled  either  with  an  ordinary  apparatus,  or,  in  the  case  of 
young  children,  by  means  of  a  steam-kettle  at  the  foot  of  a  tent-bed.  In 
some  very  acute  cases  the  use  of  ice  both  internally  and  externally  is 
advantageous.  In  suppurative  tonsillitis  with  severe  pain  the  abscess 
should  be  punctured.  Opium,  either  as  laudanum  or  Dover's  powder, 
should  be  always  given  when  there  is  much  pain,  and  is  often  very 
useful  when  there  is  none.  A  saline  mixture  with  antimonial  wine 
and  chlorate  of  potash  seems  to  be  frequently  beneficial.  Salicylate  of 
soda  is  said  by  many  to  be  of  value,  but,  as  the  rapidity  of  the  improve- 

C 


34        DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

ment  which  follows  its  use  is  never  comparable  to  the  evident  action 
of  this  drug  in  acute  rheumatism,  there  is  no  proof  of  its  specific  effect 
where  an  affection  tends  to  spontaneous  recovery  in  a  few  days.  I 
am  quite  in  accord  with  many  authorities  in  recommending  an  initial 
aperient  in  this  as  in  many  other  febrile  states  where  there  is  often  con- 
stipation at  the  outset  and  Avhere  at  least  a  feeling  of  relief  frequently 
follows  on  purgation.  The  diet  should  be  liquid  and  as  concentrated 
as  possible.  Alcohol  is  unnecessary  unless  indicated  by  the  general 
conditions. 


Chronic  Enlargement  of  the  Tonsils. 

This  affection  is  common  in  children  beyond  infancy,  especially  after 
the  age  of  five  or  six  years.  It  may  sometimes  result  from  repeated 
attacks  of  acute  tonsillitis,  but  in  my  opinion  much  more  often  begins 
gradually  apart  from  any  acute  attack  and  is  rarely  evidenced  by  local 
pain.  It  is  by  far  most  frequent  in  children  of  the  so-called  "  scrofu- 
lous "  constitution  as  indicated  by  tendency  to  glandular  enlargement  and 
ready  inflammatory  reaction  to  injuries  of  skin,  mucous  membranes, 
joints,  and  other  structures,  but  is  not  limited  to  such  cases.  The 
symptoms  are  snoring  in  sleep  and  sometimes  audible  breathing  in 
waking  hours ;  an  altered  quality  of  voice  commonly  called  "  speaking 
through  the  nose,"  and  often  a  considerable  degree  of  deafness  referable 
to  obstruction  or  occlusion  of  the  Eustachian  orifices.  There  is  frequently 
concurrent  nasal  catarrh,  and  sometimes  the  tonsils  are  so  large  that 
they  meet  with  the  uvula  and  almost  block  up  the  pharynx.  A  further 
symptom  is  a  great  liability  to  acute  attacks  of  tonsillitis  which  then  are 
very  distressing.  Swallowing  is  not  always  affected,  and  is  often  per- 
formed with  ease  in  these  chronic  cases.  I  believe  with  Henoch  that  the 
somewhat  frequent  nervous  symptoms  in  these  children,  such  as  night- 
mare and  sudden  startings  on  being  awakened  from  sleep,  are  connected 
with  obstruction  to  breathing,  and  not  referable  to  catarrh  of  the  alimen- 
tary canal,  for  in  many  there  is  no  sign  of  gastric  trouble,  and  most  if 
not  all  symptoms  often  disappear  after  a  complete  excision  of  the  tonsils. 
Adenoid  groivths  in  the  pharynx,  especially  in  the  posterior  nasal  tract, 
again  to  be  referred  to  in  connection  with  respiratory  diseases,  often 
concur  with  enlarged  tonsils.  It  is  this  complication  especially  which 
leads  to  the  great  obstruction  to  breathing  sometimes  observed,  with 
marked  retraction  of  the  lower  end  of  the  sternum  causing  somewhat 
•of  the  appearance  of  pigeon-breast.  Cough  is  frequent  in  these  cases, 
and  there  is  especially  loud  and  sonorous  expiration.  "With  the  imperfect 
aeration  of  the  blood  arising  from  this  condition  there  is  sometimes 
considerable  impairment   of   body-growth.      According  to  Dr.   Colcott 


AFFECTIONS  OF  THE  FAUCES.  3  5 

Fox,  psoriasis  and  chronic  tonsillitis,  with  or  without  adenoid  growths, 
are  often  associated  in  childhood. 

The  treatment  of  chronic  tonsillitis  consists  in  endeavouring  first  to 
improve  the  child's  general  condition  which  is  often  at  fault,  and  then 
to  diminish  or  prevent  the  local  trouble.  Often  much  is  gained  by  giving 
cod-liver  oil,  iron,  arsenic  or  strychnine,  the  tonsils  becoming  sometimes 
gradually  smaller,  or  more  often,  with  improved  general  nutrition,  ceasing 
to  enlarge  or  to  suffer  recurrent  inflammation.  But  in  all  marked 
cases  I  unhesitatingly  recommend  excision  of  the  tonsils  which,  when 
carefully  performed  by  a  competent  surgeon,  always  markedly  relieves 
and  very  often  works  a  complete  cure.  The  best  that  can  be  said  of  the 
protracted  methods  of  cauterisation  so  much  in  vogue  is  that  they  are 
scarcely  so  successful  as  even  the  frequently  incomplete  removal  of  the 
glands  Avhich  has  brought  the  radical  operation  into  the  undeserved  dis- 
repute so  much  insisted  on  by  some  specialist  adherents  of  the  slower 
methods  of  treatment.  There  are  few  better  instances  of  the  invaluable 
aid  of  surgery  to  medicine  than  the  many  cases  of  chronic  suffering 
which  may  be  rescued  from  chronic  and  expensive  maltreatment  by  this 
single  operation,  involving  neither  previous  "training"  of  the  patient 
nor  any  considerable  after-care.  I  am  convinced  further  that  there  is 
no  objection  to  the  operation  even  when  unnecessarily  performed. 

Retro-pharyngeal  Abscess. 

It  is  of  great  importance  to  remember  and  search  for  this  disease  in 
all  cases  of  throat  trouble  in  young  children,  especially  in  those  under 
two  years  old.  I  do  not  doubt  that  many  cases  run  their  favourable  or 
it  may  be  fatal  course  undetected,  not  only  from  forgetfulness  to  explore 
the  pharynx  with  the  finger,  but  also  from  the  frequent  situation  of  the 
abscess  either  in  the  naso-pharynx  or  behind  the  larynx.  In  many 
instances  the  first  noticeable  symptom  is  dyspnoea,  when  the  abscess 
is  low  down  behind  the  larynx,  and  is  then  apt  to  be  erroneously 
referred  to  primary  laryngeal  mischief,  especially  if  there  be  any  cough 
or  hoarseness.  If  on  the  other  hand  the  abscess  be  in  the  naso- 
pharynx, there  is  obstruction  to  breathing  through  the  nose,  which, 
when  accompanied,  as  it  frequently  is,  by  a  thick  nasal  discharge  and 
glandular  and  areolar  swelling  in  the  neck,  may  closely  simulate  at  first 
sight  either  scarlatinal  or  diphtheritic  disease.  The  simplest  cases  both 
for  diagnosis  and  treatment  are  those  where  the  abscess  is  in  the  inter- 
mediate part  of  the  pharynx  within  easy  reach  of  the  finger  and  gives 
rise  to  some  dysphagia  as  the  first  and  most  prominent  symptom. 

The  affection  consists  in  inflammation  leading  to  abscess  in  the  sub- 
mucous tissue  of  the  pharynx  in  front  of  the  spine,  and  is  by  far  most 


36        DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

often  seen  in  the  first  few  years  of  life.  The  origin  of  most  cases  is 
very  doubtful.  My  own  experience  is  in  accord  with  that  of  Professor 
Henoch,  who,  quoting  from  the  large  number  of  sixty-five  cases  observed 
by  himself,  very  strongly  contradicts  the  prevalent  belief  that  either 
spinal  caries  or  the  scrofulous  condition  is  a  common  cause,  and  shows 
that  the  majority  of  sufferers  are  previously  healthy.  A  certain  number 
have  their  origin  undoubtedly  in  measles  or  in  scarlatina,  instances  of  both 
of  which  I  have  seen.  In  the  unexplained  majority  undiscovered  trau- 
matism from  swallowing  pieces  of  crust,  bone,  or  other  hard  substances 
may  possibly  play  a  greater  part  than  can  ever  be  demonstrated. 

If  a  retro-pharyngeal  abscess  be  undiscovered  and  therefore  untreated 
it  frequently  bursts  with  the  disappearance  of  all  symptoms,  but  not 
seldom  the  pus  burrows  in  various  directions.  It  may  cause  suffocation 
by  pressure  on  the  larynx  or  by  discharging  into  it,  may  rupture  into 
the  auditory  meatus,  or  may  largely  invade  the  areolar  tissue  of  the 
neck,  giving  rise  to  great  swelling  and  sometimes  pointing  externally. 
Occasionally  the  pus  extends  to  the  mediastinum  and  may  open  into  the 
oesophagus  or  the  pleura.  Many  cases  come  first  under  observation  with 
much  cervical  swelling  on  one  or  both  sides  according  to  the  situation 
of  the  abscess.  This  should  always  excite  a  suspicion  of  the  probable 
cause  when  accompanied  by  dysphagia  or  dyspnoea.  In  perhaps  a 
majority  of  cases  the  abscess  is  not  literally  retro-pharyngeal  in  situa- 
tion, but  forms  on  one  side  of  the  pharynx,  causing  often  great  unilateral 
swelling. 

There  are  rarely  any  notable  symptoms  of  onset,  but  there  may  be 
some  fever  with  or  without  slight  rigors.  Some  pain  and  tenderness  are 
probably  constant,  but  seldom  early  detected,  and  there  may  be  stiffness 
of  the  neck  with  the  head  kept  back  or  on  one  side.  When  the  abscess 
is  low  down  the  dyspnoea  and  stridor  from  pressure  on  the  larynx  may 
be  great,  although  dysphagia  may  not  be  very  prominent.  The  stridor, 
however,  unlike  that  of  most  laryngeal  mischief  except  extensive  mem- 
branous blocking,  accompanies  expiration  as  well  as  inspiration,  and 
although  both  cough  and  hoarseness  of  voice  or  cry  may  be  present  they 
are  very  often  absent,  and  never  approach  in  intensity  to  the  similar 
symptoms  of  primary  laryngeal  disease.  Swelling  and  especially  fluctua- 
tion in  the  neck  in  cases  of  this  kind  are  an  additional  help  to  the  right 
diagnosis.  Mr.  Scott  Battams  informs  me  that  he  has  been  twice  able 
by  observation  of  these  points  to  relieve  completely  and  at  once  by 
external  incision  cases  of  extremely  urgent  dyspnoea  to  which  he  had 
been  summoned  for  the  performance  of  tracheotomy. 

In  cases  where  the  abscess  is  high  up  in  the  naso-pharynx  and  there 
is  impeded  nasal  breathing  with  perhaps  nasal  discharge,  but  no  laryn- 
geal difficulty,  scarlatinous  and  diphtheritic  affection  of  the  fauces  may 


AFFECTIONS  OF  THE  FAUCES.  37 

usually  be  excluded  by  the  absence  of  their  proper  signs  on  inspection 
of  the  pharynx,  and,  if  •  we  still  suspect  diphtheria  limited  in  its  local 
expression  to  the  naso-pharynx,  the  presence  of  much  external  swelling 
will  go  very  far  to  exclude  it  and  to  corroborate  the  diagnosis  of  retro- 
pharyngeal abscess.  A  careful  examination  with  the  finger  passed  up 
into  the  naso-pharynx  behind  the  soft  palate  will  usually  detect  the 
swelling  and  thickening  caused  by  an  abscess,  but  in  one  case  of  my 
own  arising  after  measles  in  which,  from  much  cervical  swelling,  impeded 
nasal  breathing  and  absence  of  faucial  or  laryngeal  signs,  I  thought  of 
abscess,  nothing  was  detected  by  repeated  digital  examination.  The 
child  soon  died,  apparently  with  septicaemia,  a  dusky  rash  being  observed 
the  day  before  death,  and  an  unburst  abscess  was  found  very  high  up  in 
the  naso-pharynx  with  great  inflammatory  thickening  of  the  tissues. 
Although  the  cervical  swelling  in  this  case,  mainly  on  the  right  side, 
was  not  fluctuant  I  greatly  regret  that  I  did  not  at  once  order  free 
incision. 

It  should  be  remembered  that  a  small  abscess  at  the  back  of  the 
visible  pharynx  which  but  slowly  increases  may  be  evidenced  by 
nothing  else  for  some  time  than  by  the  infant's  crying  while  sucking  or 
otherwise  feeding,  or  by  its  taking  very  little  at  a  time.  Something 
appears  to  ail  the  child  who  may  waste  somewhat  and  become  flabby.  I 
have  seen  a  case  in  point  where  an  infant  without  any  noted  sign  of 
local  pain  had  been  treated  dietetically  for  about  ten  days  with  all  perse- 
verance but  no  success.  A  sudden  suspicion  that  there  might  be  some 
oral  or  pharyngeal  trouble  led  me  to  inspect  the  mouth  and  explore 
the  fauces  with  the  finger,  and  thus  to  discover  at  once  a  small  retro- 
pharyngeal abscess  Avhich  was  quickly  relieved  by  puncture. 

In  all  cases,  therefore,  of  doubtful  trouble  in  the  throat  of  young 
children  a  thorough  exploration  of  the  pharynx  should  be  made.  If  an 
abscess  be  found  it  should  be  opened  at  once  Avith  the  proper  surgical 
precautions  of  guarded  bistoury  and  medianly-directed  incision,  and  the 
child's  head  should  be  quickly  bent  forwards  after  this  operation.  Aspi- 
ration of  the  abscess,  recommended  by  some,  is  open  to  the  objection  of 
possibly  necessary  repetition.  Much  external  swelling  when  the  internal 
abscess  is  out  of  sight  and  reach,  and  especially  fluctuant  swelling, 
indicates  external  opening  which  is  often  followed  by  immediate  relief 
and  rapid  subsidence  of  symptoms. 


38        DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 


CHAPTER    IV. 

GASTRO-INTESTINAL    DISORDERS. 

In  the  heading  of  this  chapter,  which  will  he  mainly  concerned  with 
the  common  and  prominent  trouhles  of  vomiting  and  diarrhoea  in  infancy 
for  the  most  part  referable  to  gastric  dyspepsia,  I  have  for  practical 
purposes  departed  from  the  systematic  or  anatomical  classification  of 
disorders  of  the  alimentary  tract  according  to  which  the  affections  of 
the  stomach  and  of  the  intestines  would  he  separately  treated  from  the 
point  of  view  of  structural  disease. 

Although  such  morbid  conditions  of  this  tract  as  catarrhal  inflamma- 
tion and  even  some  degree  of  ulceration  are  more  or  less  frequently 
associated  with  the  affections  to  he  discussed  and  may  play  in  turn  a 
symptomatic  part  of  their  own,  yet  they  are  very  often  absent,  as  evi- 
denced by  post-mortem  examination  in  even  very  chronic  cases,  and 
must  mainly  be  regarded  when  present  as  the  result  rather  than  the 
source  of  the  disorders  they  accompany.  That  a  catarrhal  condition  of 
the  stomach  or  intestines  may  be  sometimes  inferred  with  much  pro- 
bability from  the  nature  of  the  vomit  or  fasces,  and  that  in  certain  cases 
ulceration  of  the  bowel  may  be  strongly  indicated  by  the  passage  of 
blood  from  the  anus  is  not  to  be  questioned,  but  I  would  emphatically 
teach  that  in  the  gastro-intestinal  disorders  of  infants  which  especially 
concern  us  now  the  less  we  picture  "  catarrh  "  as  a  substantive  condition 
in  our  setiological  diagnosis  of  the  cases  before  us,  and  the  more  we 
think  of  the  functions  of  digestion  and  absorption  and  the  subtler 
changes  underlying  their  disorder,  the  better  our  hygienic,  dietetic  and 
medicinal  treatment  will  be. 

First  considering,  therefore,  the  general  subject  of  vomiting  and 
diarrhoea,  with  their  frequently  associated  symptoms  of  abdominal  dis- 
tress or  general  disturbance,  as  pointing  chiefly  to  gastric  dyspepsia,  I 
shall  subsequently  deal  with  the  different  morbid  conditions  of  the 
stomach  and  intestines  which,  whether  strictly  primary  or  not,  may  be 
indicated  by  special  symptoms  or  found  post-mortem. 

Vomiting". 

The  import  of  vomiting  as  an  indication  of  chronic  gastric  dyspepsia 
depends  mainly  on  consideration  of  the  condition  of  its  subjects,  the 
nature  of  the  food  taken,  and  of  the  clinical  association  of  other  symp- 


GASTROINTESTINAL  DISORDERS.  39 

toms,  especially  diarrhoea  and  wasting.  I  have  already  spoken  generally 
of  this  symptom  of  stomach  trouble  from  dietetic  causes  and  of  its  treat- 
ment in  connection  with  the  subject  of  infantile  atrophy,  and  must 
further  allude  to  it  under  the  head  of  diarrhoea  with  which  in  its  most 
serious  forms  it  is  far  most  frequently  associated.  It  is  therefore  suf- 
ficient here  to  treat  of  vomiting  mainly  from  the  diagnostic  point  of  view 
in  its  various  clinical  relationships. 

In  young  infants  otherwise  healthy  vomiting  is  frequently  seen  as 
the  result  of  overfilling  the  stomach,  the  small  size  of  which  is  often 
forgotten  in  feeding  them  either  from  the  breast  or  the  bottle.  Such 
regurgitation  of  food  is  as  a  rule  not  excessive,  and  is  immediately  sequent 
upon  sucking.  In  the  absence  of  failure  of  nutrition  or  any  other  sign 
of  ill-health  there  is  no  cause  for  anxiety  even  although  this  vomiting  be 
often  recurrent,  but  smaller  and  sometimes  perhaps  more  frequent  meals 
are  certainly  indicated.  When,  however,  vomiting  is  persistent  and 
copious,  and  still  more  when  it  does  not  follow  immediately  on  feeding, 
it  should  at  once  be  regarded  as  morbid  and  indicative  of  dyspepsia  with 
its  possible  train  of  accompaniments  and  sequelae.  Before  therefore  any 
further  symptoms  arise  the  general  condition  of  the  child  and  the  quality 
of  its  diet  must  be  carefully  considered.  Sudden  acute  vomiting  in  a 
healthy  child,  accompanied  by  eructations  and  by  evidence  of  abdominal 
pain  or  discomfort,  often  points  at  once  to  undigested  food  as  the  cause, 
but  it  must  be  remembered  that  although  usually  some  diarrhceal  and 
other  symptoms  soon  follow  on  continued  dyspeptic  vomiting  yet  chronic 
vomiting  may  often  lead  to  rapid  and  serious  wasting  without  other 
definite  symptoms,  at  least  for  some  time,  and  even  with  constipation. 
In  such  cases  the  meals  are  ejected  before  any  considerable  absorption 
can  take  place ;  thirst  is  excessive,  and  the  infant  will  perhaps  take 
greedily  any  food  that  is  offered  it ;  the  tongue  may  be  furred  or  later 
become  red  and  dry  ;  and  thrush  may  appear  in  the  mouth.  Death 
may  result  from  pure  exhaustion,  or  may  be  immediately  due  to  pul- 
monary collapse  or  inflammation  or  to  sinus-thrombosis  with  coma  or 
convulsions. 

In  such  cases  as  these  unaccompanied  by  diarrhoea  there  is  very  often, 
and  in  my  experience  mostly,  some  further  cause  than  improper  feed- 
ing which,  however,  doubtless  often  plays  a  very  large  part.  In  some 
instances  neither  careful  feeding  nor  any  medicine  gives  material  help, 
and  we  usually  find  that  just  in  proportion  as  the  food  is  apparently 
appropriate  there  are  indications  in  the  child  of  previous  ill-health  or 
evidence  of  anaemia  or  of  some  other  general  malady.  Not  to  mention 
several  cases  of  this  kind  in  children  who  were  the  subjects  of  scrofula 
and  therefore  perhaps  of  gastric  catarrh  as  part  of  the  catarrhal  disorder 
so  frequent  in  that  affection,  I  have  seen  many  instances  of  obstinate 


4-0         DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

vomiting  and  fatal  wasting  in  infants  who  had  previously  suffered  from 
syphilitic  symptoms,  and  have  indeed  been  often  led  to  a  suspicion  of 
syphilis,  confirmed  by  subsequent  inquiry,  from  the  mere  existence  of 
vomiting  and  wasting  recalcitrant  to  all  treatment.  To  syphilitic  wasting, 
however,  often  without  either  diarrhoea  or  vomiting,  I  shall  allude  further 
in  its  proper  place.  Rickets  and  the  conditions  of  low  vitality  from 
defective  hygiene  so  generally  incident  on  poverty  must  also  be  reckoned 
with,  besides  strictly  dietetic  improprieties,  as  important  factors  in  the 
production  of  dyspepsia  with  vomiting  and  deficient  absorption. 

In  many  cases  of  chronic  vomiting  gastric  catarrh,  as  the  result  of 
irritant  or  undigested  food,  probably  contributes  to  persistence  of  the 
symptom,  and  is  evidenced  by  the  ejection  of  much  mucus.  Consti- 
jmtion  and  flatulence  are  here  often  observed,  but  usually  there  is 
diarrhoea.  I  must,  however,  repeat  that  it  is  the  exception  to  find 
any  post-mortem  evidence  of  affection  of  the  gastric  mucosa,  even  in 
the  most  chronic  cases  of  vomiting  with  or  without  diarrhoea. 

Before  attributing  vomiting,  whether  often  repeated  or  not,  to  the 
above-mentioned  group  of  causes  we  must  exclude  as  far  as  possible 
other  affections  of  which  it  may  be  symptomatic.  It  may  be  the  ear- 
liest or  the  most  prominent  mark  of  cerebral  disease,  such  as  tumour 
or  meningitis,  but  it  is  then  sooner  or  later  accompanied  by  headache, 
cardiac  irregularity,  or  some  of  the  many  other  signs  indicative  of  its 
true  cause,  and  is  usually  unattended  by  other  ordinary  signs  of  gastric 
disorder  such  as  furred  tongue,  gaseous  eructation,  abdominal  pain  or 
diarrhoea,  It  is  often  however  directly  occasioned  in  cerebral  cases 
by  the  taking  of  food.  Vomiting  is  also  very  often  the  first  observed 
symptom  of  acute  febrile  diseases,  among  which  the  exanthemata — espe- 
cially scarlet  fever, — pneumonia  and  tonsillitis  are  prominent,  and  it  is 
frequent  in  pertussis  as  well  as  in  many  cases  of  pulmonary  disorder 
with  cough.  The  accompaniment  of  fever  and  the  sequence  of  some 
of  the  characteristic  symptoms  and  signs  of  the  above-mentioned  affec- 
tions will  usually  clear  up  doubt.  Febrile  attacks  however  with  gastric 
symptoms  in  children  mostly  beyond  infancy  not  infrequently  occur, 
and  may  be  mentioned  here  although  they  are  often  probably  not  of 
gastric  origin.  The  onset  may  be  sudden  with  vomiting,  high  tem- 
perature, and  even  some  delirium.  In  some  cases  there  is  diarrhoea,  in 
others  constipation,  and  there  may  be  cough  or  hurried  breathing  with 
or  without  harsh  respiratory  or  dry  crepitant  sounds.  These  attacks 
are  usually  of  but  a  day  or  two's  duration,  but  are  apt  to  recur  with 
various  intervals  free  from  gastric  symptoms,  and  are  often  unassociated 
with  any  discoverable  dietetic  error.  A  nervous  origin  has  been  sug- 
gested for  these  symptoms  in  some  cases  with  much  apparent  reason 
owing  to  their  sudden  appearance  after  excitement,  to  their  frequently 


CASTRO-INTESTINAL  DISORDERS.  41 

sudden  subsidence,  and  to  the  tendency  of  their  subjects  to  suffer  from 
other  nervous  disorders.  In  some  instances  these  attacks  usually,  he  it 
noted,  interpreted  as  arising  from  "  the  stomach,"  or  in  medical  language 
from  "  acute  gastric  catarrh,"  are  proved  by  the  sequel  or  by  careful 
examination  to  be  connected  with  unsuspected  tonsillitis  or  pneumonia. 
Sometimes  their  origin  is  by  no  means  apparent,  and  in  the  absence 
of  all  evidence  of  dietetic  causes  I  prefer  no  diagnosis  to  the  theory 
of  gastric  catarrh  arising  idiopathically  or  occasioned  by  a  conveniently 
hypothetical  chill. 

Whenever  vomiting  occurs  with  pyrexia,  especially  in  children  heyond 
infancy,  we  should  think  of  the  possibility  of  enteric  fever  before  decid- 
ing on  purgative  treatment  which  in  many  instances  may  be  beneficial. 
An  emetic  in  such  cases  is  mostly  advisable  and  always  innocent  even 
while  Ave  still  stand  in  doubt,  and  a  single  purge,  if  generally  indicated, 
will  probably  do  no  harm  whatever  the  illness  prove  to  be. 

Intestinal  obstruction,  and  especially  intussusception,  must  also  be 
remembered  as  a  cause  of  vomiting  which  may  be  the  first  symptom 
noticed.  It  is  probably  only  in  children  of  over  six  or  seven  years  of 
age  that  nervous  vomiting,  which  is  by  no  means  rare,  need  be  thought 
of.  Such  vomiting  may  or  may  not  be  excited  by  food,  is  mostly 
accompanied  by  other  signs  of  nervous  disturbance,  and  is  often  pro- 
minent in  plainly  hysterical  patients. 

The  treatment  of  that  most  important  form  of  persistent  vomiting  in 
infants  which  is  primarily  due  to  gastric  derangement  and  mostly  associ- 
ated with  diarrhoea  is  chiefly  dealt  with  under  the  headings  of  Infantile 
Wasting  and  Diarrhoea.  It  need  therefore  only  be  said  here  that  dyspeptic 
vomiting  must  be  treated  mainly  on  dietetic  principles,  medicines  being 
regarded  as  adjuncts.  When  vomiting  is  urgent  the  greatest  rest  pos- 
sible for  the  stomach  is  necessary,  and  much  benefit  in  recent  cases  can 
be  derived  from  giving  nothing  but  water  for  a  day  or  even  sornewhat 
longer  with  an  occasional  small  dose  of  diluted  alcohol.  In  more  severe 
cases  indicating  longer  rest  to  the  stomach  nutrient  enemata  of  pan- 
creatised  or  peptonised  milk,  or  of  meat  peptones,  in  bulk  not  exceeding 
from  half  to  one  fluid  ounce  at  a  time,  should  be  tried.  The  rectum 
must  be  carefully  cleaned  out  by  a  water-injection  before  the  nutrient 
enema  is  given.  As  a  merely  symptomatic  remedy,  if  nothing  else,  for 
dyspeptic  vomiting  especially  when  accompanied,  as  it  is  in  most  acute 
and  many  chronic  cases,  by  epigastric  pain  and  eructation  due  to  acid 
fermentation  in  the  stomach,  an  alkali  such  as  sodium  bicarbonate  in  an 
aromatic  water,  with  or  without  a  minim  or  two  of  syrup  of  ginger  or 
compound  tincture  of  chloroform,  is  certainly  most  valuable.  It  is  true, 
as  urged  by  Henoch  and  others,  that  an  alkali  only  neutralises  the  acid 
formed  by  the  fermenting  contents  of  the  stomach,  and  does  not  touch 


42         DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

the  morbid  process  itself  ;  but  while  deferring  the  question  of  the  best 
possible  causal  treatment  of  gastric  dyspepsia  I  would  express  my  con- 
viction that  not  only  does  far  more  effectual  relief  to  the  vomiting  and 
pain  result  from  the  alkaline  treatment  than  from  the  hydrochloric  acid, 
calomel,  salicylates,  creasote  and  other  remedies  given  for  their  supposed 
anti-fermentative  or  anti-septic  action,  but  that  the  stomach  being  thus 
kept  at  comparative  rest  for  a  while  in  many  cases  soon  becomes  able  to 
respond  to  the  curative  effect  of  an  appropriate  diet  which  prevents  fer- 
mentative processes.  Bismuth  subnitrate  with  or  without  small  doses 
of  the  aromatic  powder  of  chalk  and  opium  often  gives  valuable  addi- 
tional help.  When  cases  of  this  kind  are  taken  early  under  treatment 
appropriate  diet  alone  after  a  preliminary  purgation  by  castor-oil  or 
calomel  Avill  often  cause  rapid  improvement.  It  is  at  this  time  also 
that  the  anti-fermentative  class  of  remedies  I  have  mentioned  might  be 
expected  to  be  useful;  but  in  obstinate  cases  which  respond  but  little 
or  not  at  all  to  dietetic  treatment  I  must  confess  that  my  experience  of 
these  medicines  has  ended  mostly  in  disappointment.  When  urgent 
symptoms  have  subsided  in  any  case  of  gastric  vomiting,  leaving  the 
child  very  weak,  some  of  the  peptonised,  pancreatised  or  malted  foods, 
substituting  artificial  for  natural  digestion,  are  often  of  much  temporary 
value.  To  papain  as  a  help  to  digestion  my  experience  has  not  been 
favourable ;  in  chronic  and  otherwise  obstinate  cases  it  is  I  think  quite 
useless.  The  all-important  dietetic  treatment  should  be  undertaken 
and  patiently  persevered  with  on  the  general  principles  laid  down  in  the 
chapter  on  atrophy.  I  believe  with  Dr.  Goodhart  that  those  who  use 
the  simplest  methods,  with  due  ingenuity  as  regards  detail,  with  the  aid 
of  a  faithful  and  intelligent  nurse  and  with  complete  disregard  of  the 
reported  success  or  failure  of  any  previous  treatment,  are  the  most  likely 
to  effect  the  desired  cure. 

Acute  vomiting  and  empty  retching  may  often  be  relieved  or  checked 
by  the  application  of  a  light  mustard  poultice  or  hot  stupes  to  the  abdo- 
men. In  some  chronic  and  unyielding  cases  of  vomiting  even  in  quite 
young  infants  occasional  or  daily  washing  out  of  the  stomach  with  warm 
water  as  recommended  by  Epstein  and  others  and  largely  practised  by 
Seibert  of  New  York  is  of  undoubted  value.  Food  should  be  withheld 
for  at  least  two  hours  after  the  operation  and  then  given  in  very  small 
quantities.  It  is  often  better  to  administer  nourishment  for  a  while 
through  a  tube  passed  into  the  stomach  by  the  mouth  or  nose,  this 
method  apparently  favouring  the  retention  of  food  by  avoidance  of  the 
reflex  effects  of  swallowing  until  such  time  as  the  nervous  irritability  of 
the  stomach  be  allayed. 


(iASTRO-INTKSTINAL   l)IS(  »H  DKRS.  43 


Diarrhoea. 

Under  this  clinical  term  I  include  all  cases  where  the  prominent 
symptom  is  frequent  liquid  discharge  from  the  bowels  whatever  its 
character  and  whether  accompanied  or  not  by  undigested  food,  much 
mucus,  blood,  or  other  morbid  material.  Although  the  nature  and 
conditions  of  diarrhceal  stools  may  often  indicate  some  more  or  less 
definite  morbid  state  of  the  intestines  or  stomach  there  is  no  possibility 
in  most  cases  of  making  an  serological  or  anatomical  diagnosis  from 
this  standpoint,  severe  diarrhoea  often  occurring  with  no  special  post- 
mortem signs  visible  to  the  naked  eye  in  the  alimentary  canal,  extensive 
ulceration  being  sometimes  observed  when  there  has  been  no  diarrhoea, 
and  cases  clinically  similar  being  very  frequent  with  widely  differing 
intestinal  lesions.  The  diagnosis  therefore  of  the  probable  cause  which 
is  the  chief  basis  for  the  proper  treatment  of  diarrhoea  must  depend  mainly 
on  clinical  considerations  of  the  conditions,  concomitant  symptoms  and 
history  of  each  case  or  group  of  cases. 

The  clinical  division  of  diarrhoea  in  childhood  into  Acute  and  Chronic 
is  at  once  salient  and  practical,  and  it  may  be  said,  although  with  im- 
portant exceptions  hereafter  to  be  noticed,  that  cases  of  the  first  class 
are  not  as  a  rule  referable  to  gross  lesions  of  the  alimentary  canal  as  their 
immediate  cause  whereas  in  many  of  the  latter  class  such  lesions  may  be 
inferred  or,  in  fatal  instances,  are  discoverable  to  a  greater  or  less  extent. 
Chronic  diarrhoea  too,  with  or  without  marked  inflammatory  or  ulcerative 
signs  in  intestine  is  often  the  result  of  acute  diarrhoea  from  whatever 
cause  arising. 

Acute  Diarrhoea. — Diarrhoea  beginning  more  or  less  suddenly,  whether 
attended  or  not  by  gastric  symptoms  or  by  fever,  and  whether  transient 
or  ingravescent  in  character,  is  by  far  most  common  in  children  under 
two  years  of  age,  is  ultimably  referable  in  a  large  majority  of  cases  to 
improprieties  in  the  quality  or  quantity  of  food,  and  is  greatly  favoured 
by  warmth  of  season  and  bad  hygienic  surroundings  of  all  kinds.  Chil- 
dren fed  exclusively  at  the  breast  supply  but  a  small  contingent  to  the 
diarrhoea  total  even  among  the  poor  of  large  cities,  but  since  in  these 
classes,  on  Avhom  the  incidence  of  infantile  diarrhoea  is  by  far  the  heaviest, 
this  manner  of  feeding  at  least  according  to  hospital  experience  in  London 
is  decidedly  rare  even  during  the  first  six  months  of  life,  we  find  no  great 
immunity  from  the  worst  forms  of  diarrhoea  among  infants  of  the  suckling 
age.  The  majority  of  cases,  however,  in  my  experience  as  in  that  of 
others,  such  as  Dr.  Emmett  Holt's  in  New  York,  who  deals  with  large 
numbers  in  Infant  Asylums,  is  met  with  in  the  second  half  year  of  life,  a 
period  during  which  nearly  all  the  children  of  the  poor  and  some  of  the 


44         DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

well-to-do  are  from  necessity  or  ignorance  miscellaneously  and  improperly 
fed.  Both,  the  incidence  and  mortality  of  diarrhoea  though  considerably 
less  than  at  the  last-mentioned  period  continues  enormously  high  until 
the  age  of  two  years  after  which  it  diminishes  with  great  rapidity. 
Although  space  forbids  me  to  quote  evidence  for  the  conclusion  that  in 
a  large  majority  of  cases  of  infantile  diarrhoea  the  probable  cause  is  the 
poisonous  activity,  in  promoting  decomposition  or  fermentation  in  the 
alimentary  canal,  of  bacteria  introduced  with  the  food  and  especially  in 
milk,  I  would  state  at  the  outset  that — after  careful  consideration  of  the 
conditions  in  which  diarrhoea  arises — such  a  doctrine  seems  to  me  prac- 
tically established,  and  this  in  spite  of  the  fact  that  no  constant  or 
demonstrably  specific  form  of  infective  micro-organism  has  as  yet  been 
discovered  in  the  dejecta  of  any  group  of  cases  with  however  character- 
istically similar  symptoms.  Many  and  elaborate  bacteriological  researches 
have  been  made  into  this  question,  and  I  would  especially  refer  to  those 
of  Drs.  Booker  and  Jeffries  published  in  the  Transactions  of  the  American 
Pediatric  Society  for  1889.  Dr.  Jeffries'  observations  go  far  to  prove 
that  the  large  class  of  summer  diarrhoeas  is  the  result  of  the  products  of 
bacterial  growth  in  the  food  and  in  the  alimentary  canal,  and  indicate 
the  paramount  necessity  of  sterilising  all  milk  that  is  given  to  infants  in 
almost  all  cases.  In  this  matter  of  vital  importance  the  line  of  treatment 
thus  pointed  out  should  be  followed  without  waiting  for  the  more  certain 
setiological  and  diagnostic  knowledge  which  may  probably  be  hopefully 
looked  for.  In  the  light  of  analogy  from  other  infective  diseases  we 
may  infer,  from  the  acuteness  of  so  many  of  these  cases  of  infantile 
diarrhoea  and  the  favourable  conditions  to  germ-development  in  food  or 
otherwise  among  which  they  arise,  that  they  are  largely  of  microbic,  and 
probably  of  multifariously  microbic  origin. 

Before,  however,  describing  in  more  detail  this  important  and  exten- 
sive class  of  cases  which  occur  mostly  in  the  summer  months  and  are 
often  of  epidemic  nature  I  would  call  attention  to  the  also  common 
forms  of  diarrhoea  of  generally  less  dangerous  character  which,  although 
possessing  no  very  distinctive  symptoms  and  in  many  instances  not 
perhaps  to  be  denied  bacterial  origin,  seem  at  least  to  be  primarily 
caused  by  demonstrable  improprieties  of  diet  and  to  be  often  relieved 
or  soon  cured  by  due  attention  to  feeding  and  general  hygiene.  Some 
of  these  cases  are  merely  temporary,  characterized  mainly  by  increased 
peristaltic  action  and  fluid  secretions  from  intestine,  and  due  to  un- 
digested or  irritating  material  passing  from  the  stomach  to  the  bowels. 
Beyond  some  abdominal  pain  in  those  which  begin  suddenly  and  the 
prostration  which  results  from  all  diarrhoeas  these  cases  may  have  no 
other  marked  symptoms,  neither  vomiting  nor  fever  being  necessarily 
present.     Rest,  a  preliminary  purge  followed  by  bismuth  and  opium  if 


GASTROINTESTINAL  DISORDERS.  45 

the  discharges  be  not  very  soon  controlled,  and  the  blandest  or  almost 
starvation  diet  for  a  short  time  is  the  necessary  treatment  for  this  class 
of  cases.  With  predisposed  and  weakly  infants,  and  in  bad  hygienic 
and  other  favouring  conditions  such  attacks  may  however  rapidly  become 
grave  or  chronic. 

In  many  other  instances  we  have  to  deal  with  acute  diarrhoeas,  gene- 
rally in  infants  artificially  fed,  which  are  accompanied  by  undoubted 
signs  of  gastric  disturbance  such  as  vomiting  of  milk-curds  or  other 
undigested  matter,  evidence  of  abdominal  pain  and  much  furring  of  the 
tongue,  and  are  often  though  by  no  means  always  marked  by  varying 
degrees  of  pyrexia.  There  is  frequently  much  thirst,  and  the  motions  are 
copious  and  of  either  a  dark-brown  or  greenish  colour  with  or  without 
visible  undigested  material.  After  a  while  fever,  if  present,  may  dis- 
appear, and  pain  and  vomiting  may  cease,  leaving  only  diarrhoea,  in  the 
form  of  frequent  and  foul-smelling  liquid  motions,  to  mark  the  case.  If 
not  soon  checked  by  appropriate  dietetic  and  medicinal  treatment  some 
or  all  of  these  symptoms  may  rapidly  increase,  and  wasting  with  all  the 
dangerous  phenomena  of  exhaustion  may  ensue  as  in  the  typical  instances 
of  summer  diarrhoeas,  presently  to  be  noticed,  from  which  indeed  these 
cases  are  not  to  be  too  strictly  distinguished.  I  only  mention  them 
separately  to  emphasize  the  great  importance  of  thinking  at  once  of 
dietetic  causes  in  all  diarrhoeas  however  slight  or  severe  they  may  be  and 
of  promptly  treating  them  from  this  point  of  view.  It  is  especially  in 
such  attacks  where  there  is  evidence  of  initial  gastric  disturbance,  of  im- 
proper food  or  of  undigested  matter  in  the  faeces,  Avhether  or  no  there  be 
accompanying  fever,  that  prompt  treatment  may  be  rapidly  curative  and 
stay  the  progress  of  the  case  towards  gastro-intestinal  catarrh  or  inflam- 
mation of  either  acute  or  chronic  kind.  Many  of  these  patients  who 
escape  the  common  event  of  early  death  first  come  under  our  notice  as 
well-marked  instances  of  entero-colitis  with  abundance  of  mucus  and 
often  more  or  less  blood  in  the  discharges  from  the  bowels. 

From  the  milder  instances,  then,  of  infantile  diarrhoea  with  but  little 
gastric  disturbance  and  little  fever  we  may  find  all  grades  up  to  the 
acutest  kind  which  from  its  greater  prevalence  in  the  warm  season  is 
known  as  summer  diarrhoea  or,  under  its  gravest  aspects,  as  "  cholera 
infantum."  The  onset  and  course  of  these  cases,  which  are  so  frequent  in 
cities  and  crowd  the  wards  and  out-patient  rooms  of  hospitals  for  chil- 
dren in  London  from  July  to  August  and  often  later,  are  veiy  various, 
and  we  are  frequently  unable  to  distinguish  practically  as  regards  forecast 
between  those  which  begin  gradually  with  but  few  symptoms  other  than 
diarrhoea,  and  those  where  the  attack  is  sudden  with  vomiting  and  much 
fever.  In  many  there  is  of  course  a  history  of  bad  feeding  with  a  longer 
or  shorter  period  of  malaise  and  wasting  previous  to  the  special  symptoms 


46        DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

complained  of ;  in  many,  equally  of  course,  there  is  evidence  of  syphilis, 
rickets,  a  history  of  previous  whooping-cough  or  measles  or  other  affec- 
tions favouring  or  causing  diarrhoeal  symptoms  and  intestinal  catarrh ; 
but,  also  in  many,  impropriety  of  diet,  other  than  that  connected  with 
bacterial  contamination,  can  probably  or  certainly  be  excluded,  and 
previously  healthy  and  well-cared-for  infants  frequently  suffer  and  not 
seldom  succumb.  It  is  in  this  latter  class  of  patients  and  especially 
when  there  is  a  high  febrile  onset  with  vomiting  that  a  bacterial  origin 
specially  forces  itself  upon  our  minds.  With  regard  to  the  significance 
of  fever  in  these  cases  as  a  whole  I  would  say  that  many  which  run  a 
favourable  course  under  appropriate  treatment  begin  with  gastric  symp- 
toms and  some  fever ;  that  many  which  become  rapidly  worse  and  some 
with  even  the  symptoms  known  as  "  cholera  infantum "  may  have  no 
fever  at  the  beginning  and  little  or  perhaps  none  at  the  fatal  end ;  but 
that  continued  fever  is  always  of  the  gravest  prognosis  and  when  over 
1030  F.  almost  always  indicates  death.  Continued  vomiting  is  also  a 
very  dangerous  symptom,  and  is  usually  present  with  continued  fever. 
On  the  whole  it  may  be  said,  in  spite  of  the  many  fatal  cases  I  have  seen 
without  fever,  that  a  persistently  normal  temperature,  other  things  being 
equal,  contributes  to  a  favourable  prognosis. 

In  proportion  to  the  amount  of  the  diarrhoea  there  is  wasting  and  pros- 
tration which  may  be  excessive  even  in  cases  which  recover.  The  stools 
usually  lose  their  normal  yellow  colour  almost  from  the  beginning,  be- 
coming green,  brown  or  gray,  are  frequently  accompanied  by  flatus,  and 
have  a  foul  odour.  In  some  cases  they  are  excessively  profuse  and 
watery  -with  at  first  sickening  and  later  but  little  smell.  "With  this 
condition  especially  the  symptoms  may  be  those  of  rapid  collapse  and 
practically  indistinguishable  from  those  of  Asiatic  cholera.  Eapid  and 
early  collapse  may  however  take  place  with  profuse  liquid  motions  while 
the  stools  are  still  feeculent  and  in  such  cases  too  we  observe  the 
apathetic  or  drowsy  condition,  the  dry  skin,  the  extreme  pallor  or 
cyanosis,  the  cutaneous  chilliness,  the  sunken  eyes,  the  depressed  fonta- 
nelle,  the  disordered  breathing,  the  rapid  irregular  action  of  the  heart,  and 
the  weakness  or  impalpability  of  the  peripheral  pulses  which  together  form 
a  salient  example  of  the  conditions  often  described  as  "hydrocephaloid." 
The  head  may  also  be  markedly  retracted  as  in  other  cases  of  profound 
exhaustion,  and  the  secretion  of  urine  is  diminished  or  arrested. 

In  most  of  the  large  number  of  cases  which  run  a  slower  course  either 
to  recovery,  to  more  or  less  chronicity,  or  to  death  the  infants  continue 
restless  and  are  apparently  in  abdominal  pain,  with  distended  belly  and 
drawn-up  legs,  until  in  the  worst  instances  symptoms  of  exhaustion  become 
predominant  and  drowsy  apathy  supervenes.  The  tongue  is  coated  or 
more  often  dry  and  red,  and  the  thirst  is  excessive. 


GASTROINTESTINAL  DISORDERS.  47 

Broncho-pneumonia  and  collapse  of  lung  often  follow  or  concur  with 
the  abdominal  symptoms  and  may  be  the  immediate  cause  of  death. 
Convulsions  may  accompany  the  onset  of  the  disease  in  some  cases 
marked  by  much  pyrexia,  and  are  frequent  just  before  the  fatal  end. 

In  a  certain  number  of  cases,  after  the  subsidence  of  gastric  symptoms 
and  more  or  less  diminution  of  the  fever  which  may  have  been  present, 
obstinate  but  slighter  diarrhoea  remains  with  markedly  mucous  or  bloody 
stools  indicating  probably  the  existence  of  intestinal  inflammation,  but 
I  would  record  here  the  warning  not  to  regard  bloody  stools,  even  if 
frequent  and  plentiful,  which  last  but  a  few  days  as  necessarily  or  usually 
the  result  of  ulceration.  In  many  severe  examples  of  gastro-intestinal 
disturbance,  both  in  children  and  adults,  poisonous  or  acutely  irritating 
articles  of  diet  may  cause  so-called  dysenteric  stools  in  marked  degree 
which  are  doubtless  the  result  of  intense  intestinal  congestion.  In  the 
frequent  cases  where,  after  the  subsidence  of  acute  symptoms  and  of  all 
vomiting,  diarrhoea  alone  remains  in  the  form  of  frequent,  small  and 
foul-smelling  liquid  motions,  and  wasting  progresses  in  spite  of  careful 
feeding  and  symptomatic  medicinal  treatment,  the  irremediable  fault 
seems  to  lie  in  the  failure  of  intestinal  absorption.  In  many  such  cases 
no  catarrh  or  coarse  lesion  is  found  after  death,  although  usually  the 
intestines  are  much  thinned  and  the  glands  atrophied.  The  instances 
of  profuse  diarrhoea  with  symptoms  of  collapse  which  may  be  charac- 
terized as  "cholera  infantum"  are  not,  according  to  my  experience,  to 
be  practically  distinguished  otherwise  than  by  these  salient  marks  and 
a  mostly  fatal  tendency  from  the  great  class  of  acute  diarrhoeas  which 
we  regard  as  due  to  decomposition  of  food  or  fermentation  within  the 
alimentary  canal  as  the  probable  result  of  bacterial  poisoning.  Nor  are 
such  instances,  though  confessedly  not  very  frequent,  quite  so  rare  here 
as,  according  to  Dr.  Emmett  Holt,  they  would  appear  to  be  in  New 
York.  Although  most  cases  of  this  nature  die  in  spite  of  all  treatment, 
including  those  who  have  been  healthy  and  in  good  condition  up  to  the 
time  of  the  acute  seizure,  yet  some  recover  after  sinking  into  a  state  of 
deep  collapse.  Prognosis  is  worst  with  a  very  high  temperature  and  in 
very  young  infants  with  a  history  of  untoward  surroundings  and  of 
previous  disease,  especially  diarrhoea. 

In  many  instances  these  choleraic  symptoms  are  not  observed  from 
the  first  but  follow  on  a  stage  of  previous  diarrhoea  with  or  without 
marked  evidence  of  intestinal  inflammation.  After  death,  however,  in 
cases  of  rapid  course  anatomical  signs  of  intestinal  mischief  other  than 
microscopical  evidence  of  loss  of  epithelium  are  usually  absent. 

The  early  diagnosis  of  the  nature  and  import  of  cases  of  acute  diar- 
rhoea, especially  in  children  beyond  earliest  infancy,  involves  some  prac- 
tical considerations  other  than  those  of  merely  the  state  of  the  alimentary 


48        DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

canal.  It  is  not  of  much  moment  as  regards  treatment,  although  it 
may  he  ultimately  as  regards  prognosis,  to  decide  whether  or  no  there  is 
evidence  of  intestinal  catarrh  or  inflammation  in  any  given  case.  The 
more  violent  the  symptoms  and  the  more  continuous  the  pyrexia  the 
more  likely  such  a  condition  becomes,  but  we  must  remember  that  in 
many  cases  of  acute  onset  which  may  last  even  for  weeks  no  special 
appearances  are  noted  post-mortem. 

Eather  should  we  trouble  ourselves  to  exclude  other  affections  which 
may  be  marked  at  their  onset  by  fever,  vomiting  and  diarrhoea,  or  may 
be  frequently  accompanied  by  diarrhoea  as  the  result  of  impaired  diges- 
tion. Thus  in  many  acute  diseases  such  as  measles,  pneumonia,  scarla- 
tina, and  others  there  may  be  sometimes  much  initial  diarrhoea,  and  in 
every  case  with  fever  we  should  make  a  complete  physical  examination 
for  local  signs  including  inspection  of  the  throat,  and  wait  for  the  period 
of  distinctive  symptoms  of  the  exanthemata  before  finally  pronouncing 
our  diagnosis. 

Acute  attacks  of  diarrhoea  again  are  especially  liable  to  be  developed 
without  discoverable  dietetic  errors  in  infants  who  are  the  subjects  of 
rickets  or  syphilis.  They  may  possibly  be  due  to  chill  and  certainly 
often  accompany  attacks  of  bronchial  or  nasal  catarrh ;  but  marked 
diarrhoea  as  an  isolated  symptom  is  in  my  opinion  but  rarely  attri- 
butable with  any  plausibility  to  intestinal  catarrh  as  the  result  of  cold 
alone.  It  is  well  to  remember  that  occasionally  obstruction  of  the  bowel 
by  intussusception  may  be  symptomatically  ushered  in  by  vomiting  with 
liquid  evacuations  from  the  parts  below  the  lesion,  and  that  sometimes 
even  the  later  symptom  of  nielsena  may  possibly  be  confused  Avith  the 
result  of  enteritis.  Increased  vomiting,  however,  with  arrested  intestinal 
flux  and  other  signs  of  intussusception  will,  as  a  rule,  soon  resolve  doubt. 
The  acute  diarrhoeas  of  children  beyond  two  years  old  are  generally  more 
or  less  demonstrably  due  to  dietetic  errors  when  not  merely  a  part  of 
more  general  disease,  acute  or  chronic,  although  some  may  possibly  be 
due  to  cold.  With  persistent  pyrexia  and  distended  and  tender  belly 
inflammation  or  ulceration  of  the  intestines,  especially  of  the  colon, 
may  be  suspected.  Tubercular  diarrhoea  is  as  a  rule  chronic,  and  in 
enteric  fever  initial  diarrhoea  is  but  rarely  prominent. 

The  naked-eye  and  other  characteristics  of  the  stools  in  cases  of 
diarrhoea  should  always  be  noted  whether  minute  microscopical  or 
chemical  research  into  their  nature  be  possible  or  not.  Examination  of 
the  stools  may  be  of  considerable  practical  use  in  acute  cases,  while  in 
chronic  it  is  very  often  of  high  importance. 

In  a  healthy  suckled  infant  the  stools  are  of  a  more  or  less  bright 
yellow  colour,  of  pasty  consistency,  acid  reaction  and  slightly  sour  smell. 
Their  frequency  varies  from  three  to  five  or  six  during  the  first  few 


GASTROINTESTINAL  DISORDERS.  49 

weeks,  after  which  time  they  may  he  from  one  to  three  until  weaning  time. 
With  a  more  mixed  diet  the  stools  gradually  assume  the  adult  characters 
until,  after  two  or  three  years  old,  they  are  in  no  way  specialised. 

Very  watery  stools  are  always  a  had  sign,  occurring  when  small  and 
frequent  in  chronic  cases,  and  heing  hoth  frequent  and  profuse  in  the 
so-called  cholera  infantum.  In  the  latter  the  reaction  is  generally  neutral 
or  alkaline. 

Green  stools  are  very  common  in  acute  diarrhoea  and  may  persist  even 
in  some  chronic  cases.  According  to  the  best  evidence  it  appears  that 
this  colour  is  due  to  biliverdin  and  implies  an  alkaline  condition  in  some 
part  of  the  alimentary  canal  which  is  abnormal  in  infants  wholly  fed  by 
the  breast. 

Stools  may  be  of  very  dark  colour  from  various  causes.  Besides  alimen- 
tary disorder  raw  meat-juice  and  certain  drugs  such  as  bismuth  and  iron 
will  turn  them  dark  brown  or  black,  as  also  will  blood  from  the  upper 
part  of  the  canal.  Much  visible  mucus,  or  mucus  and  red  blood  in  the 
stools  point  often  to  an  inflammatory  or  ulcerative  condition  of  the  colon 
or  rectum.  According  to  Emmett  Holt's  observations  the  more  intimately 
mixed  this  mucus  is  with  the  stool  the  higher  is  its  source  in  the  intes- 
tine. The  mucous  shreds  he  mentions  as  sometimes  resembling  false 
membrane  and  distinguishable  from  it  by  being  very  readily  broken 
down  by  a  stream  of  water  I  have  seen  from  time  to  time.  Definite 
false  membranes  as  the  possible  result  of  colitis  are  scarcely  ever  seen  in 
infancy  and  but  rarely  in  childhood.  I  have  had  no  experience  among 
children  of  this  condition  which  according  to  many  observers  is  most 
frequent  in  young  adult  women  of  neurotic  tendency  in  connection  with 
chronic  gastro-intestinal  disorder. 

Masses  due  to  undigested  food  in  the  stools  are  common,  but  are  more 
especially  important  in  chronic  cases.  Lumps  of  casein  are  frequently 
seen  in  the  diarrhceal  stools  of  milk-fed  infants,  and  round  masses  of  fat 
are  often  abundant.  Starch  may  occur  in  large  quantities,  revealed  by 
microscopic  examination  or  by  the  iodine  test. 

Morbid  anatomical  signs  in  the  intestines  of  cases  of  infantile  diarrhoea 
of  the  class  we  are  considering  are  often,  as  I  have  said,  practically  absent, 
and  when  present  vary  considerably  with  no  certain  relationship  to  the 
symptoms  observed  during  life.  It  is  however  roughly  true  that  the 
more  severe  and  febrile  the  case,  and  the  longer  its  duration,  the  more 
likely  we  are  to  find  some  naked-eye  evidence  of  intestinal  catarrh  or 
inflammation  such  as  mucous  coating,  or  more  especially,  distinct  vascular 
congestion  of  the  lining  membrane  of  the  bowels,  chiefly  in  the  colon 
and  ileum.  Much  swelling  of  the  solitary  glands  or  of  Peyer's  patches 
is  also  often  seen,  and  sometimes  superficial  destruction  of  the  mucosa 
over  irregular  areas  as  the  result  of  catarrhal  inflammation  may  be  found 

D 


50        DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

if  carefully  looked  for.  Ulceration  of  these  glands,  usually  known  as 
"  follicular  "  enteritis,  is  observed  in  some  of  the  subacute  cases  which 
run  a  somewhat  protracted  course  towards  death  without  much  or  any 
fever.  These  ulcers  are  usually  small  and  superficial  but  sometimes 
penetrate  beneath  the  mucosa;  they  are  mostly  situated  in  the  colon 
though  sometimes  seen  above  the  caecal  valve.  Neither  meleena  nor  any 
other  clinical  symptom  distinguishes  this  kind  of  ulceration,  which,  as 
Dr.  Emmett  Holt  observes  judging  from  the  excessively  rare  occurrence  of 
healed  ulcers  in  the  intestines  of  infants,  is  probably  nearly  always  fatal. 
The  lesson  I  have  learned  from  post-mortem  examination  in  cases  of  acute 
and  subacute  infantile  diarrhoea  is  that  the  conception  of  catarrh  or  of 
any  other  morbid  condition  of  the  intestines  is  not  very  helpful  towards 
treatment,  and  I  am  quite  in  accord  with  Holt's  conclusion,  based  on 
much  observation  both  macroscopical  and  microscopical,  that  attempts  at 
anatomical  subdivision  of  this  class  of  cases  are  of  no  clinical  value.  I 
would  however  refer  the  reader  both  on  this  and  other  points  to  Dr. 
Holt's  article  on  "  The  Diarrhceal  Diseases  "  of  children  in  vol.  iii.  of 
Keating's  Cyclopaedia,  as  the  most  masterly  and  thoroughly  practical 
account  of  the  subject  within  my  knowledge. 

The  post-mortem  fact  of  severe  entero-colitis  in  some  cases  of  infantile 
diarrhoea  and  vomiting  will  be  referred  to  for  the  sake  of  convenience  in 
the  next  chapter.  Entero-colitis  is  indeed  to  be  regarded  as  for  the  most 
part  secondary  to  more  or  less  prolonged  attacks  of  diarrhoeal  disturbance, 
and  has  no  claim  to  a  separate  serological  position. 

The  treatment  of  cases  of  acute  and  subacute  infantile  diarrhoea  con- 
sists mainly  in  removing  or  antagonizing  its  chief  cause  by  the  institution 
of  appropriate  diet ;  in  giving  medicines  to  check  the  intestinal  flux  and, 
if  it  be  possible,  to  arrest  morbid  processes  in  the  alimentary  canal ;  and 
in  securing  the  best  hygienic  and  other  conditions  for  recovery. 

Rest  in  bed  with  avoidance  of  chill  and  as  much  fresh  air  and  light 
as  possible  are  necessary  for  all  the  worst  and  youngest  cases,  while  those 
beyond  early  infancy  and  of  less  acute  character  may  be  carried  out  of 
doors  for  a  while  in  favourable  weather  if  they  be  kept  strictly  at  rest. 
Absolute  cleanliness  should  be  observed,  all  soiled  linen  being  quickly 
removed,  and  daily  or  more  frequent  tepid  bathing  is  advisable. 

In  respect  of  diet,  the  acuter  the  diarrhoea  and  vomiting  with  or  with- 
out fever,  the  more  important  it  is  to  keep  the  stomach  at  rest,  and  in 
cases  seen  at  the  outset  nothing  should  be  given  for  several  hours  or 
perhaps  a  day  or  more  besides  frequent  small  quantities  of  cold  water 
which  has  been  boiled,  or  barley-water,  to  allay  the  thirst  which  is 
always  present  and  to  compensate  for  the  loss  of  fluid  by  the  bowel. 
Repeated  small  doses  of  brandy  will  however  generally  be  needed. 
Very  small  quantities  of  milk  or  other   food  appropriately  diluted  or 


GASTROINTESTINAL  DISORDERS.  5  I 

otherwise  treated,  according  to  the  methods  described  in  the  chapter 
on  wasting,  and  not  without  lime-water,  should  then  be  tried,  after  one 
preliminary  purge  of  from  half  a  drachm  to  a  drachm  of  castor-oil  or 
half  a  grain  of  calomel  for  a  child  from  six  months  to  a  year  old.  At 
this  early  stage  I  give,  as  already  stated  under  the  heading  of  vomit- 
ing, 4  or  5  grain  doses  of  bicarbonate  of  soda  in  some  aromatic  water 
every  four  or  six  hours,  believing  it  to  be  practically  useful  in  allaying 
discomfort  and  lessening  the  tendency  to  vomit.  Should  the  symptoms 
continue  or  increase,  or  the  diarrhoea  be  great,  we  must  check  the  flux 
if  possible,  and  among  other  remedies  which  may  be  tried  in  various 
cases  io  grains  or  more  of  bismuth  subnitrate  combined  with  5  grains 
of  the  aromatic  powder  of  chalk  and  opium  is  generally  the  most 
efficacious.  In  all  severe  and  continuing  attacks  of  acute  diarrhoea,  with 
or  without  vomiting,  astringent  treatment  is  necessary,  and  I  believe 
that  opium  in  some  form,  carefully  proportioned  to  the  case  and  the 
age,  its  safe  action  being  judged  of  by  its  observed  effects,  is  almost 
indispensable. 

The  milk  which,  as  I  have  said,  we  should  first  try  in  very  small 
quantities  in  quite  early  cases,  after  granting  some  hours'  rest  to  the 
stomach,  is  exceedingly  often  rejected ;  we  must  then  give  no  more  until 
the  acute  symptoms  have  subsided.  "We  may  try  for  a  while  small 
quantities  of  raw  or  nearly  raw  meat-juice  with  or  without  a  little  sugar, 
or  of  some  of  the  peptonised  preparations  of  meat-juice,  or  may  tide  over 
a  day  or  two  with  beef -tea  or  veal-broth,  or  with  white  of  egg  dissolved 
in  water  which  has  been  boiled,  of  the  strength  of  one  or  two  eggs  to  a 
pint, — all  in  small  quantities  at  a  time, — having  recourse  again  to  milk, 
with  lime-water,  as  soon  as  marked  improvement  has  set  in.  During 
all  this  time,  and  indeed  in  most  cases  from  the  very  first,  repeated  doses 
of  alcohol  are  necessary,  children  of  under  a  year  old  often  taking  from 
20  minims  to  half  a  drachm  every  two  hours  or  even  more  with  advan- 
tage. The  necessity  for  this  drug,  however,  and  its  quantity  depend  of 
course  on  the  general  indications  in  each  individual  case.  It  is  usually 
valuable  in  direct  proportion  to  the  amount  of  diarrhceal  flux. 

It  is  impossible  here,  even  were  it  useful,  to  enter  into  detail  as  regards 
the  minutiae  and  alternations  of  diet  necessary  in  many  cases  of  this 
kind ;  a  part,  however,  of  this  ground  has  been  covered  in  a  general  way 
by  what  I  have  already  said  concerning  wasting.  We  have  always  to 
bear  in  mind  that  the  less  the  contents  of  the  stomach  are,  compatibly 
with  the  ingestion  of  sufficient  nutriment  to  sustain  life,  the  more  likely 
it  is  that  the  morbid  processes  in  the  alimentary  canal,  due  as  they  so 
often  are  to  bacterial  action,  will  be  discouraged.  We  must  therefore  be 
satisfied  to  give  but  little  at  a  time,  and  to  leave  if  possible  two  hours' 
interval   between   each   feeding.     The   eminently  rational   therapeutic 


5  2         DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

object  of  antagonizing  by  medicines  the  morbid  processes  of  fermentation 
resulting  from  bacterial  action  can  scarcely  be  said  to  have  been  as  yet 
attained  in  any  satisfactory  degree.  "Were  it  practicable,  this  method 
of  treatment  should  be  undertaken  in  all  cases  from  the  very  outset. 
I  have  myself  been  mostly  disappointed,  after  many  trials,  with  the 
results  of  repeated  doses  of  calomel,  of  the  hydrochloric  and  lactic  acids, 
the  salicylates,  carbolic  acid,  creasote,  resorcin,  and  other  drugs  which 
have  been  recommended  for  this  purpose.  In  the  quite  early  cases 
which,  when  not  excessively  severe,  will  often  soon  recover  if  treated  at 
once  by  the  methods  above  sketched  I  have  learned  nothing  from  the 
administration  of  antiseptic  drugs,  while  in  the  much  larger  number  of 
hospital  cases,  which  are  usually  of  some  standing  before  they  come 
under  observation,  I  have  but  very  rarely  had  much  reason  to  believe 
that  any  improvement  was  due  to  this  class  of  medicines.  I  have  nearly 
always  been  forced  to  have  recourse  at  last  to  the  bismuth  and  opium 
or  other  astringent  treatment.  In  established  cases  indeed  we  may 
have  but  little  theoretical  reason  to  hope  for  much  success  from  ger- 
micidal drugs,  for  our  knowledge  of  this  subject  at  present  points  to  the 
probability  of  rapid  absorption  of  the  poisons  generated  by  bacterial 
action.  Naphthol,  however,  now  largely  used  in  practice  for  its  anti- 
septic properties  may  possibly  prove  to  be  of  value.  Its  action  is  seen 
in  the  reduction  of  the  frequency  and  quantity  of  the  stools  and  the 
destruction  of  their  offensive  odour,  and  the  drug  is  apparently  useful 
in  this  direction  in  proportion  to  its  early  administration.  It  is  insoluble 
or  nearly  so  in  water,  and  of  disagreeable  taste ;  but  when  once  swallowed 
seems  usually  to  cause  no  further  disturbance  digestive  or  otherwise. 

Naphthalene,  hitherto  more  often  given  as  an  internal  remedy  than 
naphthol,  has  appeared  to  me  from  several  recent  trials  to  be  quite  as 
efficacious  as  naphthol  in  either  of  its  forms  and  is  considerably  cheaper. 
The  dose  of  either  drug  for  infants  is  from  2  to  4  grains  repeated 
two  or  three  times  in  the  day.  It  must  be  mentioned  here  that  bis- 
muth in  the  form  of  the  subnitrate  or  the  carbonate,  not  to  mention 
the  more  modern  and  now  much-used  preparation  of  the  salicylate,  has 
been  stated  to  possess  antiseptic  properties,  and  it  is  said  by  Dr.  Emmett 
Holt  to  be  among  the  best  of  this  class  of  remedies  and  superior  to 
naphthalene.  It  is  possible,  of  course,  that  the  recognised  usefulness  of 
bismuth  in  diarrhoea  may  be  accounted  for  by  its  antiseptic  action.  If 
bo  it  should  be  administered  as  soon  as  possible  in  all  cases.  The  anti- 
septic treatment,  however,  of  diarrhcea  and  vomiting  in  infants,  especi- 
ally in  the  acute  epidemic  cases  during  the  summer,  is  still  on  its  trial. 
The  most  difficult  and  unsatisfactory  cases  to  treat  are  those  where 
diarrhcea  of  some  kind  persists,  often  in  the  form  of  but  small  though 
offensive  liquid  motions,  after  vomiting  has  ceased,  and  where  the  child 


GASTROINTESTINAL  DISORDERS.  53 

takes  food  readily  or  even  greedily.  Most  of  these  cases,  though  they 
may  linger  long,  ultimately  die,  but  some  few  improve  with  continuous 
use  of  bismuth  and  some,  it  would  seem,  although  my  experience  here 
has  as  yet  been  comparatively  small,  with  naphthalene  or  naphthol, 
after  the  failure  of  other  treatment.  These  drugs,  being  insoluble  in 
the  stomach,  may  act,  as  some  think,  on  the  lower  bowel  which  is  the 
chief  seat  of  such  lesions  as  may  be  found  in  fatal  cases.  In  still  other 
instances,  which  in  my  experience  are  somewhat  more  numerous  than 
those  which  apparently  respond  to  drug  treatment,  gradual  improvement 
may  be  shown  after  all  medicines  have  been  stopped  and  ultimate  re- 
covery may  take  place  after  a  long  period  of  careful  nursing  and  varied 
diet  with  no  special  regard  to  theoretical  considerations.  "With  respect 
to  opium,  which  is  in  my  opinion  necessary  in  most  acute  cases  of 
diarrhoea,  with  or  without  vomiting,  mainly  for  the  purpose  of  arrest- 
ing peristaltic  action  and  thus  diminishing  the  flux  which  in  itself  is 
dangerous  or  fatal,  I  believe  that  this  drug  may  be  safely  adminis- 
tered, with  due  precaution  and  observation  of  its  effects,  to  children 
of  almost  any  age.  To  no  child  under  a  year  old  should  more  than 
j  to  h  a  minim  of  tincture  of  opium  be  given  as  a  first  dose.  The 
effect  should  be  carefully  watched,  and  subsequent  doses  regulated  accord- 
ingly. Many  infants  require  more  than  these  doses  for  any  appreciable 
result.  In  this  context  I  may  remark  that  just  as  adults  may  differ  in 
their  reaction  to  powerful  drugs  such  as  opium  and  belladonna  so  do  young 
children,  and  that  it  is  not  in  my  opinion  quite  justifiable  to  affirm  that 
children  are  more  or  less  susceptible  than  adults  to  certain  drugs  in  doses 
proportionate  to  their  age.  It  may  be  true  that  many  children  can  take 
ten-minim  doses  or  more  of  tincture  of  belladonna  without  harm,  but 
I  have  seen  several  instances  in  young  subjects  where  distinct  physio- 
logical symptoms  have  occurred  after  the  administration  of  but  half  these 
doses  for  no  very  long  time,  and  I  feel  certain  from  several  trials  that  the 
usual  ten-minim  dose  of  tincture  of  belladonna  is  too  small  for  usefulness 
in  adidts  who  can  generally  take  in  health  three  times  this  quantity 
without  appreciable  effect.  I  know  of  no  good  evidence  for  the  oft- 
repeated  statement  that  young  children  as  a  class  are  able  to  take  pro- 
portionately larger  doses  of  any  poisons  than  adults ;  nor  do  I  think  that 
babies  are  much  more  susceptible  than  their  elders  to  proportionately 
smaller  doses  of  opium. 

Stomach-washing  should  be  employed  in  cases  when  vomiting  is 
obstinate,  and  irrigation  of  the  lower  bowel,  as  described  under  the  next 
heading,  will  often  be  found  very  useful  in  acute  cases.  With  proper 
care  there  is  but  little  to  fear  from  this  operation.  In  the  acutest  form 
of  diarrhoea  and  vomiting  known  as  "  cholera  infantum  "  and  characterized 
by  great  general  irritability,  by  innumerable  and  copious  watery  motions 


54        DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

soon  becoming  neutral  or  alkaline,  and  by  rapidly  ensuing  collapse  and 
wasting,  with  sunken  fontanelle,  stupor,  coma  or  convulsions,  we  must  at 
first  give  nothing  but  frequent  small  doses  of  brandy  and  plenty  of  cold 
water  or  barley-water  to  assuage  thirst,  and  should  endeavour  at  once  to 
arrest  the  vomiting  and  diarrhoea  by  repeated  subcutaneous  injections  of 
morphia,  beginning  in  the  case  of  children  under  a  year  old  with  not 
more  than  t^q  grain.  If  vomiting  still  continue  brandy  or  ether  must 
be  injected  subcutaneously.  Hot  mustard  baths  are  to  be  ordered  in  the 
stages  of  collapse.  When  in  the  early  irritable  stage  the  temperature 
runs  high,  a  warm  bath  gradually  cooled  down  to  about  85°  should  be 
given,  and  repeated  with  subsequent  accesses  of  fever.  To  conclude 
these  remarks  on  treatment  which  I  am  conscious  are  no  more  than 
very  inadequate  hints  to  be  supplemented  by  the  practitioner's  ingenuity, 
resource,  and,  above  all,  patient  perseverance  in  each  individual  case,  I 
quote,  from  the  article  by  Dr.  Holt  above  referred  to,  the  following  words 
of  guidance  which  may  serve  to  remind  us  of  broad  principles  often 
neglected  :- — "  No  matter,"  he  says,  "  how  strongly  we  may  be  convinced 
of  the  value  of  any  drugs  or  combination  of  drugs,  if  they  continue  to 
disturb  the  stomach  they  are  worse  than  useless.  The  use  of  all  drugs  is 
of  very  minor  importance  as  compared  with  dietetic  and  hygienic  treat- 
ment. In  the  management  of  any  single  (acute)  case  the  important  points 
are  thorough  evacuation  of  the  stomach  and  bowels,  and  then  rest  to 
these  organs  again  for  from  twelve  to  twenty-four  hours.  No  cases  do 
worse  than  those  whose  mothers  cannot  appreciate  the  value  of  starvation 
and  insist  upon  giving  milk  in  violation  of  the  rules  laid  down." 

Chronic  Diarrhoea. — Chronic  diarrhoea  in  infancy  and  early  childhood 
may  be  divided  into  two  main  groups.  The  first  consists  of  those  cases 
which  are  most  often  not  referable  to  any  previous  acute  gastro-intestinal 
attack,  but  are  all  the  same  the  result  of  continued  improper  feeding,  gene- 
rally defective  hygiene,  inherent  weakness,  or  a  combination  of  these  factors. 
Whether  or  no  there  be  accompanying  intestinal  catarrh  in  some  degree 
marked  and  definite  inflammatory  changes  are  absent,  and  improvement 
or  recovery  usually  follows  if  the  removal  of  the  causal  conditions  be 
effected  before  extreme  emaciation  have  been  established.  The  second 
group  contains  most  of  the  graver  cases  which  are  either  certainly  or 
very  probably  referable  to  definite  lesions,  such  as  entero-colitis  as  the 
not  very  infrequent  result  of  more  or  less  acute  attacks  of  infantile 
diarrhoea  and  vomiting,  or  intestinal  tuberculosis. 

Instances  of  the  first  group  are  very  common  in  hand-fed  infants,  and 
in  those  who  are  the  subjects  of  rickets,  syphilis,  scrofulosis,  or  other 
general  conditions  involving  nutritive  disorder.  Many  cases  seem  to 
date  from  whooping-cough,  from  measles  and  other  exanthemata,  or  from 
broncho-pneumonia,  and  some  occur  in  tubercular  children  without  tuber- 


GASTROINTESTINAL  DISORDERS.  5  5 

cular  intestinal  disease.  The  more  marked  and  definite  the  cachexia  of 
the  child  and  its  consequent  predisposition  to  react  more  readily  to  the 
exciting  cause  of  improper  feeding  which  is  common  to  most  of  this 
class  of  cases,  the  less  hope  there  is  of  recovery  from  attention  to  dietetic 
and  hygienic  measures  alone.  Many,  however,  of  the  symptomatically 
graver  cases  with  much  wasting  and  enlarged  belly,  often  described  even 
now  by  the  terms  "tabes  mesenterica,1'  or  "consumption  of  the  bowels" 
according  to  the  social  status  of  the  patient,  recover  completely  and 
rapidly  when  properly  fed  and  cared  for,  the  diarrhoea  being  thus  clearly 
due  to  faulty  diet  with  frequently  bad  hygienic  conditions. 

Besides  the  diarrhoea  for  which  these  children  are  usually  brought, 
either  before  or  after  marked  wasting  has  set  in,  there  is  no  salient 
symptom  of  gastric  disorder,  the  appetite  being  often  good.  "With  pro- 
gressive diarrhoea  both  anaemia  and  wasting  become  prominent.  In 
established  cases  the  motions  are  frequent,  foul,  discoloured  and  watery, 
but  usually  contain  masses  of  undigested  material.  There  is  no  fever, 
although  acute  attacks  of  gastro-intestinal  disorder  are  apt  to  set  in 
after  but  slight  exciting  causes  and  especially  in  the  warmer  season. 
Neglected  diarrhoea  of  this  kind  supplies  a  large  contingent  to  the  cases 
of  chronic  infantile  wasting  already  described.  Extreme  emaciation  may 
ensue,  which  may  ultimately  defy  all  reparative  treatment;  extensive 
dermatitis  of  an  "  impetiginous  "  or  ecthymatous  character  often  occurs ; 
thrush  appears  in  the  mouth,  and  broncho-pneumonia,  often  with  masked 
symptoms,  or  an  acute  attack  of  diarrhoea  frequently  ends  the  scene  with 
or  without  convulsion  or  retracted  head. 

It  is  often  possible  to  elicit  a  history  of  the  passage  of  frequent, 
large,  offensive,  and  semi-solid  stools  before  actual  diarrhoea  or  marked 
wasting  has  set  in.  If  these  important  symptoms  of  indigestion  be  early 
observed  careful  dietetic  treatment  will  probably  preclude  the  establish- 
ment of  chronic  diarrhoea. 

In  older  children  chronic  diarrhoea  unconnected  with  marked  intes- 
tinal disease  or  tuberculosis  is  almost  always  due  to  errors  of  diet 
and  is  apt  to  be  very  obstinate  to  treatment  although  rarely  fatal.  The 
motions,  containing  undigested  matter,  are  not  so  copious  as  in  infants, 
and  wasting  is  less  marked,  but  irritability,  sleeplessness,  abdominal  dis- 
comfort and  anaemia  are  prominent.  Much  mucus  probably  indicates 
catarrh  of  the  lower  bowel.  Symptomatically  much  the  same  as  this 
form  of  dyspeptic  diarrhoea  is  that  which  is  not  referable  to  dietetic 
errors,  and  has  been  described  by  Trousseau  and  others  as  "nervous 
diarrhoea."  I  fully  recognise  the  frequency  of  this  affection  in  children, 
as  also  in  adults.  It  would  seem  that  in  these  cases  almost  any  food, 
liquid  or  solid,  except  perhaps  in  the  most  minute  quantities,  causes  undue 
peristalsis  of  stomach  and  bowels,  and  that  the  fault  lies  in  individual 


56        DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

nervous  irritability.  The  effect  on  nutrition  owing  to  the  prevention 
of  digestion  and  absorption  is  of  course  great.  There  may  or  may  not 
be  much  mucus  in  the  stools  the  frequency  of  which  varies  considerably. 
Of  chronic  diarrhoea  as  the  alleged  result  of  exposure  to  cold  or  insuffi- 
cient clothing  I  can  say  nothing  more  than  that  I  regard  such  exposure 
as  mainly  an  exciting,  although  perhaps  a  frequently  exciting,  cause  in 
children  otherwise  predisposed.  While  therefore  much  impressed  with 
the  multitudes  of  half-clothed  children  who  never  suffer  from  diarrhoea 
I  am  none  the  less  convinced  that  in  many  cases  chronic  diarrhoea  is 
much  alleviated  by  due  attention  to  the  preservation  of  body- warmth. 

The  second  group  of  chronic  diarrhoeas  are  those  connected  with 
demonstrable  intestinal  lesions,  whether  simply  inflammatory,  and  then 
usually  the  result  of  acute  diarrhoea  and  vomiting,  or  due  to  tubercular 
disease.  Clinically  these  cases  are  marked  by  prevailing  recalcitrance  to 
both  dietetic  and  medicinal  treatment,  progressive  and  excessive  wasting, 
a  dry  red  tongue,  great  tendency  to  thrush  or  to  aphthous  stomatitis, 
and  much  mucus  with  sometimes  blood  in  the  stools.  There  is  very 
often  tenderness  on  pressure  on  the  abdomen  which  is  usually  distended 
but  may  be  flat.  With  all  this  there  is  no  vomiting  and  appetite  may 
be  ravenous.  Apart  from  tubercular  disease  of  the  intestines,  to  be 
dealt  with  subsequently,  which  can  often  be  diagnosed,  even  in  the 
absence  of  pyrexia,  by  the  evidence  of  tubercle  elsewhere,  there  is  no 
absolutely  positive  means,  at  least  in  the  earlier  stages,  of  diagnosing 
this  class  of  chronic  diarrhoeas  from  the  group  already  described ;  but 
attention  to  the  above-mentioned  points  will  usually  guide  us  aright  and 
aid  us  in  making  a  prognosis.  The  presence  of  pus  in  the  stools  as 
revealed  by  the  microscope  is  a  valuable  indication  of  intestinal  inflam- 
mation or  ulceration,  as  also  is  the  discovery,  which  however  is  mostly 
prevented  by  abdominal  tumefaction,  of  enlarged  mesenteric  glands. 
These  cases  are  mostly  fatal,  their  duration  being  usually  measurable 
by  a  few  months. 

In  that  minority  of  severe  cases  which  recovers  we  may  suspect,  although 
scarcely  prove,  that  there  has  been  considerable  catarrhal  or  follicular 
inflammation  of  the  bowel,  especially  of  the  colon,  which  has  not  pro- 
ceeded to  ulceration.  The  more  acute  and  recurrent  the  symptoms  of 
the  primary  attack  or  attacks  of  gastric  disorder  which  so  often  usher 
in  this  form  of  chronic  diarrhoea  have  been,  the  graver  the  intestinal 
lesions  probably  are,  and  the  less  the  hope  of  ultimate  recovery.  The 
lesions  other  than  tubercular  found  post-mortem,  on  which  these  cases 
of  chronic  diarrhoea  depend,  are  sometimes  severe  catarrhal  inflammation 
of  the  colon  and  lower  part  of  the  ileum  but  more  often  follicular  ulcera- 
tion of  varying  degrees,  and  sometimes  patches  of  lymph  are  seen.  The 
ulcers  are  often  very  small,  and  it  may  be  remarked  here  that  in  most 


GASTROINTESTINAL  DISORDERS.  57 

cases  of  chronic  ulcerative  diarrhoea  there  is  no  hlood  in  the  stools. 
Enlargement  of  the  mesenteric  glands  is  frequently  to  be  noted. 

In  a  certain  number  of  cases  of  severe  intestinal  inflammation  with 
prolonged  diarrhoea  a  parenchymatous  nephritis  characterized  by  more  or 
less  swelling  and  granular  opacity  of  the  cortical  epithelium  has  been 
observed  by  some  and  attributed  to  the  intestinal  condition.  Occasional 
slight  albuminuria  with  or  without  oedema  and,  more  especially,  a  dry 
inelastic  state  of  the  skin  are  said  to  be  clinical  indications  of  this 
complication.  It  would  seem,  however,  that  the  connection  of  these 
phenomena  is  not  easy  to  define,  for  these  symptoms  occur  in  very 
different  disorders  and  are  by  no  means  constant  in  chronic  diarrhoea 
however  severe  and  prolonged.  The  same  morbid  appearance  in  the 
kidney  is  moreover  very  often  seen  in  association  with  high  temperature 
as,  for  instance,  in  fatal  cases  of  pneumonia  or  enteric  fever,  and  marks 
the  first  stage  of  the  well-known  scarlatinal  nephritis. 

The  treatment  of  chronic  diarrhoea  need  regard  but  little  the  question 
of  the  nature  of  the  intestinal  lesions  on  which  it  sometimes  depends, 
for  we  have  seen  that  in  proportion  as  the  diarrhoea  can  be  referred  to 
definite  enteritis  the  less  recoverable  it  is.  Practically  we  are  here 
almost  entirely  concerned  with  dietetic  and  hygienic  measures. 

The  body-warmth  must  be  maintained  by  proper  clothing,  and  with 
infants  and  young  children,  especially  when  there  is  a  history  of  pre- 
vious delicacy,  a  flannel  binder  round  the  belly  is  to  be  advised.  All 
attention,  too,  should  be  given  to  ventilation,  and  the  maximum  of  fresh 
air  and  sunlight  should  be  secured  by  changing  surroundings  where  they 
are  unfavourable. 

The  general  dietetic  treatment  is  to  be  ordered  according  to  the  prin- 
ciples laid  down  under  the  headings  of  wasting  and  gastro-intestinal 
disorders.  When  an  infant  is  brought  for  advice  for  diarrhoea  of  some 
weeks'  duration  our  methods  will  of  course  vary  somewhat,  according 
to  what  we  can  definitely  ascertain  of  its  previous  treatment.  In  most 
cases,  however,  a  properly  regulated  diet  suitable  in  quality  for  a  healthy 
infant,  though  as  a  rule  considerably  less  in  quantity,  should  be  insti- 
tuted anew  under  our  own  eyes,  whatever  we  may  have  been  told,  and 
this  alone  will  frequently  cause  rapid  improvement.  The  wasting  cases 
with  a  long  history  of  diarrhoea  which  are  successfully  treated  by  good 
nursing  and  dieting  alone  are  very  numerous.  In  some  severe  instances, 
where  we  are  satisfied  that  appropriate  diet  for  healthy  children  cannot 
be  taken,  and  remedies  such  as  peptonised  milk  and  others  directed  to 
gastric  digestion  have  failed,  we  must  resort  first  to  the  smallest  quan- 
tities of  milk  and  lime-water,  and  then,  for  a  short  while,  to  whey  with 
meat-broth,  also  in  very  small  quantities.  If,  after  a  day  or  so,  the 
diarrhoea  is  no  less  when  milk  is  given  we  must  try  raw  meat-juice, 


58         DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

prepared  according  to  the  method  before  mentioned,  or  Letter,  seeing  that 
it  is  here  the  sole  diet  for  a  time,  by  merely  pounding  some  raw  mutton 
in  a  mortar,  pressing  the  pulp  through  a  fine  sieve,  and  scraping  it  off. 
Only  about  a  teaspoonful  of  this  should  be  given  with  a  little  sugar 
or  in  some  aromatic  confection  three  or  four  times  a  day.     One  great 
advantage  of  this  food  is  its  small  bulk,  which  is  but  slightly  provocative  of 
peristalsis.     As  an  adjunct  to  this  method  of  treatment  brandy  in  10  or 
15  minim  doses  diluted  to  a  drachm  with  water  is  often  useful,  and, 
certainly,  whenever  the  intestinal  flux  is  considerable,  bismuth  subnitrate 
in  powder  with  the  aromatic  powder  of  chalk  and  opium,  in  10  to  15  grain 
doses  of  the  former  and  5  grain  doses  of  the  latter,  should  be  given  two 
or  three  times  a  day.     This  is  in  my  opinion  the  best  astringent,  and  may 
be  ordered  with  advantage  in  nearly  all  cases.     When  marked  improve- 
ment sets  in  this  medicine  and  the  brandy  should  be  discontinued,  and 
a  gradual  return  to  normal  diet  attempted.     If  the  child  even  at  its 
worst  be  very  thirsty  it  is  better  to  give  it  water  to  satisfaction  occa- 
sionally  than   in   smaller  quantities  frequently   repeated.      When  we 
have  reason  to  suspect  the  existence  of  such  a  lesion  as  colitis  underlying 
the  continuous  diarrhoea  we  must  proceed  in  the  same  way  both  as  to 
diet  and  drugs,  and  may  try  in  addition  the  effect  of  irrigation  and 
astringent  enemata.      If   ulceration  be  found   by  examination   in  the 
rectum  small  enemas  of  starch  and  opium,  not  exceeding  half  an  ounce 
or  perhaps  an  ounce  in  bulk,  should  be  used,  and  I  would  further 
recommend  them  in   all   cases  with  tenesmus   and  frequent  motions, 
whether  mixed  or  not  with  blood,  where  local  irritation  may  be  suspected 
though  not  proved.      But   in   most  cases   where   the  supposed  lesion 
is  higher  up  irrigation   and   astringent  local  treatment  are  not  satis- 
factory.     Copious   irrigation   with  warm  water   through   a   large-sized 
flexible  catheter  or  a  medium-sized  stomach-pump  tube  previously  well 
warmed  may  be  performed  daily  or  every  other  day,  and  high  injections 
subsequently  made  of  5  or  6  ounces  of  a  tannic  acid  solution  of  the 
strength  of  20  grains  to  the  ounce  or  of  some  other  astringent.     The 
tube  should,  in  either  case,  be  carefully  passed  6  or  8  inches  beyond 
the  anus.     In  obstinate  cases  this  method,  strongly  recommended  by 
many  high  authorities,  should  be  tried,  although  its  theoretical  pro- 
mise seems  greater  than  its  practical  performance.     Both  the  irrigation 
and  injection  must  be  carried  out  very  slowly,  with  careful  attention  to 
the  child's  general  condition.     Large  and  high  injections  seem  possibly 
capable  of  causing  much  reflex  shock.     Once  in  my  experience,  perhaps 
not  as  a  mere  coincidence,  collapse,  convulsion  and  death  followed  soon 
after  the   operation,  in   a   very  puny  and   chronically  wasted   infant. 
With  older  children,  owing  partly  to  their  great  caprice  of  appetite, 
dietetic  treatment  in  most  established  cases  is  not  so  soon  followed  by 


GASTRIC  AND  INTESTINAL  DISEASE.  59 

improvement  as  with  infants.  The  staple  diet  to  he  aimed  at  in  all 
cases  is  milk,  hut  it  should  he  supplemented  hy  different  kinds  of  meat- 
juices.  When  milk  disagrees  very  small  quantities  of  pounded  lean 
meat  may  he  given,  or  occasionally  the  yolk  of  an  egg  heaten  up  with  a 
little  brandy  or  sherry,  or  small  quantities  of  hread  and  hutter.  Malted 
biscuits  or  rusks  as  more  easy  of  digestion  are  recommended  by  Dr. 
Eustace  Smith  and  others,  and  pepsin  or  peptonised  foods  may  be  useful 
in  those  cases  where  continuing  gastric  dyspepsia  maintains  the  intes- 
tinal irritability.  In  all  cases  of  chronic  diarrhoea  the  greater  and  more 
direct  the  part  played  by  gastric  dyspepsia  from  improper  feeding  the 
more  tractable  are  the  symptoms,  and  the  more  simple  dietetic  treat- 
ment fails  the  greater  is  the  probability  of  incurable  lesion. 

When  convalescence  is  established  hygienic  and  dietetic  prophylaxis 
should  not  be  relaxed,  for  these  children  are  prone  to  relapse  from  slight 
causes.  Iron,  arsenic,  and  cod-liver  oil  are  each  or  all  of  frequently  good 
service  here. 

In  the  cases  above  alluded  to  of  "  nervous  diarrhoea  "  which,  at  least  in 
older  children,  are  not  rare  and  can  often,  after  a  while,  be  diagnosed 
with  considerable  confidence,  dietetic  treatment  is  of  small  value.  Other 
nervous  symptoms  are  usually  present,  and  we  cannot  then  rely  chiefly 
on  drugs  for  cure.  But  in  all  such  cases  small  doses  of  opium,  according 
to  age,  repeated  about  three  times  a  day  will  tend  to  control  materially 
the  bad  gastro-intestinal  habit,  and  sometimes  are  alone  curative.  For 
the  rest,  change  of  scene,  outdoor  life  and  the  nervine  tonics  are  highly 
important.  For  a  short  time  in  some  cases  the  sedative  influence  of  the 
bromides  is  very  helpful. 


CHAPTER  V. 

GASTRIC    AND    INTESTINAL    DISEASE. 

In  the  preceding  chapter  the  greater  part  of  the  subject  of  gastro-intestinal 
disorder  has  been  dealt  with  from  the  clinical  point  of  view,  and  we  have 
seen  that  such  disorder  hears  as  a  rule  no  certain  relationship  to  discover- 
able morbid  states.  It  remains  for  us  now  to  notice  shortly  some  of  the 
diseased  conditions  of  the  stomach  and  bowels  which  may  be  inferred 
with  all  probability  or  are  found  post-mortem,  and  are  often,  though  by 
no  means  always,  evidenced  by  more  or  less  definite  symptoms.  The 
subject  of  typhlitis  and  perityphlitis  will  be  treated  in  a  subsequent 
chapter. 


60        DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 


Affections  of  the  Stomach. 

Substantive  disease  of  the  stomach  figures  but  slightly  in  childhood. 
Ulceration  is  rare,  and  for  the  most  part  tubercular  in  connection  with 
general  tuberculosis.  It  has  been  observed  in  very  young  infants.  The 
symptoms  are  the  same  as  in  the  adult  affection,  but  small  ulcerations 
both  single  and  multiple  may  occur  with  no  symptoms  at  all.  Dr. 
Goodhart l  reports  a  case  in  an  infant  two  days  old  where  a  small  gastric 
ulcer  was  found  to  be  the  cause  of  fatal  haemorrhage  from  the  mouth  and 
anus.  I  may  here  incidentally  refer  to  other  causes  of  hsematemesis 
with  or  without  rnelaena  in  young  children,  such  as  ulceration  of  the 
cardiac  end  of  the  oesophagus  of  which  Henoch  gives  an  instance,  and 
capillary  haemorrhage  which  has  been  seen  in  several  cases  and  inferred 
in  others  and  may  perhaps  be  sometimes  attributable  to  increase  of  venous 
pressure  from  great  respiratory  obstruction.  The  hemorrhagic  diathesis 
again,  or  purpura,  may  cause  haematemesis,  which  in  these  cases  is  often 
accompanied  by  cutaneous  eruption  or  bleeding  from  other  mucous  mem- 
branes. Epistaxis,  oral  or  faucial  ulceration,  and  the  sucking  of  sore 
nipples  may  also  be  the  source  of  blood  in  vomit,  and  gastro -intestinal 
haemorrhage  is  occasionally  seen  in  the  malignant  forms  of  the  exan- 
themata, especially  of  small-pox.  The  treatment  of  gastric  haemorrhage, 
whether  due  to  ulceration  or  not,  involves  no  special  consideration  in 
childhood. 

With  regard  to  gastric  cancer  I  need  only  say  that  a  very  few  cases 
have  been  reported. 

Of  gastric  catarrh.  I  must  speak  somewhat  more  in  detail,  for  although 
its  presence  is  as  a  rule  only  inferable  from  symptoms,  and  post-mortem 
examinations  even  in  cases  of  long-standing  gastric  disorder  give  little 
colour  to  the  teaching  that  it  is  to  be  regarded  as  a  primary  affection, 
yet  it  is  doubtless  frequent  in  greater  or  less  degree  as  the  result  of 
irritation  by  indigestible  food  or  of  poisonous  decomposition  of  food 
either  before  or  after  ingestion,  and  tends  to  aggravate  and  prolong  the 
disorder  out  of  which  it  arises.  Whether  gastric  catarrh  is  a  common 
source  of  disorder  apart  from  the  above-mentioned  causes  or  from  some 
more  widespread  disease,  such  as  the  strumous  constitution  in  which 
the  glandular  system  is  specially  apt  to  suffer,  is  a  point  on  which 
authorities  differ  much.  In  my  own  opinion  there  is  not  much  clinical 
evidence  in  favour  of  giving  it  a  much  more  independent  nosological 
position  in  children  than  in  adults,  and  it  is  usually  admitted  that  in 
adults  both  the  severe  and  acute  as  well  as  the  chronic  forms  are 
mainly  due  to  some  recognisable   irritant  or  to  plain   indiscretions  in 

1  Pathological  Society's  Transactions,  1881,  vol.  xxxii. 


GASTRIC  AND  INTESTINAL  DISEASE.  6  I 

diet  or  drink.  A  chill  either  general  or  arising  from  undue  exposure 
of  the  ahdomen  is  frequently  stated  to  be  a  cause  of  gastric  catarrh 
in  young  children,  as  presumably  evidenced  not  only  by  feverishness, 
vomiting  or  bowel  derangement  either  in  the  direction  of  diarrhoea  or 
constipation,  but  also,  and  even  apart  from  such  symptoms,  by  sallow 
complexion,  disturbed  sleep,  irritability,  abdominal  pain,  syncope  or 
convulsions.  I  believe  that  most  or  nearly  all  of  such  cases  are  capable 
of  'further  ^etiological  analysis,  and  that  they  can  usually  be  referred 
either  to  demonstrable  dietetic  causes  or  to  nervous  or  some  other 
general  disorder.  In  some  of  these  so-called  gastric  attacks  which  begin 
suddenly  and  are  attended  by  fever  there  is,  as  I  mention  again  under 
the  heading  of  Pyrexia,  a  concurrent  affection  of  breathing  with  more 
or  less  evidence  of  bronchitis  which  is  as  temporary  as  the  fever  and 
the  gastric  symptoms.  I  do  not  deny  that  more  children  than  adults 
may  suffer  from  even  tolerably  severe  gastric  catarrh  as  a  part  of  a 
general  catarrhal  condition  evidenced  by  the  state  of  the  nasal  or  bron- 
chial passages,  or  that  in  scrofulous  and  rickety  children  this  affection 
is  probably  excited  with  great  readiness ;  but  I  fail  to  recognise  the 
frequency  of  gastric  catarrh,  febrile  or  non-febrile,  acute  or  chronic, 
however  indicated,  affecting  otherwise  healthy  children  as  the  mere 
result  of  "  cold."  This  view  however  by  no  means  weakens  the  great 
importance  of  attention  to  warmth  of  clothing  and  other  hygienic 
measures  in  the  treatment  of  all  nutritive  disorders  in  infants  and 
young  children. 

Gastric  catarrh  is  practically  important  from  the  therapeutical  point 
of  view  as  the  substantive  cause  of  symptoms  in  proportion  to  the 
suddenness  and  acuteness  of  those  symptoms  and  their  idtimate  refera- 
bility  to  some  definite  source  of  gastric  irritation.  "We  may  infer  the 
existence  of  gastric  catarrh  with  approximate  certainty,  after  the  ex- 
clusion of  other  disease,  when  there  is  anorexia,  headache,  abdominal 
discomfort  and  vomiting  of  food,  followed  by  retching  and  vomiting 
of  much  mucus  which  persists  after  the  stomach  is  empty.  In  cases 
which  are  accompanied  by  pyrexia,  especially  when  this  is  persistent, 
we  must  ever  be  on  the  look-out  for  the  characteristic  signs  of  other 
and  more  general  disorders,  and  whether  the  temperature  is  normal  or 
not  we  must  not  lose  sight  of  the  possibility  of  cerebral  disease.  In  the 
acuter  forms  of  gastric  catarrh  diarrhoea  is  often  prominent. 

The  more  chronic  forms  of  gastric  catarrh  as  the  result  of  continued 
ingestion  of  improper  food  depend  on  less  certain  inference  for  their 
diagnosis.  Practically  chronic  catarrh  of  the  stomach  is  not  of  much 
importance  either  in  diagnosis  or  treatment,  for  we  are  constantly  met 
with  the  fact  that,  however  well-marked  the  symptoms  may  be  which 
many  authorities  confidently  attribute  to  gastric  catarrh  as  a  cause,  post- 


62        DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

mortem  examination  in  such  cases  reveals  but  little  evidence  of  this 
condition.  A  chronic  gastric  catarrh  which  is  not  discoverable  post- 
mortem need  not  be  the  central  object  of  our  attention  during  life,  and 
it  must  be  confessed  that  none  of  the  classical  symptoms  so  often  referred 
to  chronic  gastric  catarrh  are  in  any  way  characteristic  of  this  state,  and 
that  they  all  may  occur  when  it  is  practically  absent.  I  would  remark 
here  that  many  cases  of  short  duration,  marked  slightly  if  at  all  by 
feverishness  or  urgent  stomach  symptoms  but  rather  by  nausea  and 
flatulence  or  occasional  vomiting,  with  furred  tongue,  irregular  bowel 
action,  headache,  pallor  and  other  signs  of  disturbed  circulation  such  as 
cold  extremities  or  even  syncope,  which  are  often  put  down  to  gastric 
catarrh,  are  really  of  nervous  origin  and  are  very  frequently  connected 
with  a  definite  family  history  of  various  neuroses  and  followed  in  the 
individual  by  established  migraine  or  other  nervous  disorder  in  later  life. 
I  have  seen  instances  of  marked  epilepsy  treated  as  "  gastric  catarrh," 
which  has  in  the  terminology  of  some  authorities  an  indefinitely  compre- 
hensive pathogeny.  Some  of  the  above-mentioned  attacks  may  indeed 
be  excited  by  dietetic  errors  and  relieved  by  appropriate  treatment,  but 
a  large  number  are  quite  independent  of  such  origin  and  yield,  if  they 
yield  to  treatment  at  all,  to  measures  directed  to  the  care  of  the  nervous 
system. 

The  more  chronic  cases  with  like  symptoms  in  older  children,  marked 
by  alternating  constipation  and  diarrhoea,  attacks  of  abdominal  pain, 
pallor,  languor,  wasting,  variable  appetite  and  often  a  dry  cough  are 
usually,  as  is  well  known,  referred  to  chronic  gastro-intestinal  catarrh. 
From  my  experience  however  of  these  cases,  which  are  quite  common, 
I  agree  with  Dr.  Goodhart  in  recognising  in  them  a  generally  strong- 
neurotic  relationship.  They  are  apt  to  begin  suddenly  without  ascer- 
tainable cause ;  they  usually  respond  but  little  to  merely  dietetic  or 
medicinal  treatment,  but  often  readily  improve  with  general  hygienic 
measures  and  change  of  scene  and  surroundings;  and  they  are  very 
frequently  characterized  by  prominent  symptoms  and  history  of  neurotic 
disorder. 

In  the  treatment  of  cases  of  acute  gastric  catarrh  from  whatever  cause 
arising  absolute  rest  to  the  stomach  is  before  all  things  indicated  at  first, 
and  even  for  some  days  only  small  quantities  of  liquid  food  should  be 
given.  An  initial  emetic  is  often  very  useful,  and  if  nausea  or  vomiting 
be  still  prominent  the  stomach  should  be  thoroughly  washed  out  with 
warm  water.  Alkalies,  such  as  bicarbonate  of  soda  or  potash  in  some 
aromatic  vehicle  are  often  valuable  as  aids  in  treatment.  All  farinaceous 
substances  and  sweets  should  be  forbidden,  and  a  very  gradual  return  be 
made  to  the  normal  diet. 

In  suspected  instances  of  chronic  gastric  catarrh  such  dietetic  and 


GASTRIC  AND  INTESTINAL  DISEASE.  63 

medicinal  treatment  .as  indicated  in  the  chapter  on  gastrointestinal 
disorders  should  he  followed  without  undue  consideration  of  any  hypo- 
thetical condition  of  the  stomach.  It  is  especially  however  in  those 
cases  where  there  is  excess  of  mucus  in  the  vomit  that  repeated  washing 
out  of  the  stomach  "will  he  found  useful. 


Intestinal  Catarrh  and  Enteritis. 

I  have  already  treated  of  clinical  symptoms  often  seen  in  connection 
with  intestinal  catarrh.  From  constant  irritation  of  undigested  and 
decomposing  food  a  chronic  intestinal  catarrh  is  often  set  up  which  in 
spite  of  all  treatment  may  result  in  a  severe  or  ulcerative  colitis.  The 
acute  forms  of  colitis  are  mostly  evidenced  hy  fever,  great  restlessness 
succeeded  later  on  hy  an  apathetic  condition,  dryness  and  redness  of 
tongue  with  frequent  stomatitis,  distension  and  tenderness  of  the  abdo- 
men, or  by  more  or  less  diarrhoea  with  mucus  in  excess  and  not  seldom 
blood  in  varying  quantity.  On  the  other  hand  we  find  from  time  to  time 
in  the  post-mortem  examination  of  children  who  have  died  from  various 
diseases  and  without  diarrhoea  a  marked  intestinal  catarrh  and  sometimes 
severe  enteritis  with  extravasations  or  fibrinous  exudation.  I  have  seen 
hsemorrhagic  enteritis  of  the  ileum  and  colon  in  a  case  of  febrile  wast- 
ing with  no  other  marked  symptoms  where  tubercle  was  suspected  but 
nowhere  found.  Henoch  reports  two  cases  of  marked  gastro-enteritis 
without  bowel  symptoms  in  connection  with  chronic  nephritis,  in  one  of 
which  the  post-mortem  examination  showed  the  ileum  to  be  covered  in 
places  at  its  lower  part  with  a  coherent  fibrinous  membrane,  and  Good- 
hart  quotes  one  of  severe  "  diphtheritic  "  inflammation  of  the  colon  and 
rectum  where  there  was  only  towards  the  end  some  watery  diarrhoea 
with  slight  melsena.  In  most  instances  where  definite  inflammation  or 
ulceration  of  the  colon  and  lower  part  of  the  ileum  is  found  post-mortem 
there  is  a  history  of  a  previous  attack  of  gastro-intestinal  disorder,  but 
in  some  the  intestinal  symptoms  are  alone  observed  from  the  outset, 
beginning  either  gradually  or  suddenly  with  much  fever  and  constitutional 
disturbance.  When  there  is  much  blood  in  this  latter  class  of  cases  the 
term  dysentery  is  often  used,  but  I  would  subscribe  to  the  opinion  of 
Dr.  Emmett  Holt  that  the  mere  appearance  of  considerable  blood  in  the 
stools  is  insufficient  to  establish  a  special  form  of  the  affection.  It  must 
be  remembered  that  blood  is  often  seen  in  the  stools  in  many  cases  of 
chronic  diarrhoea  which  recover,  and  does  not  necessarily  imply  ulcera- 
tion, while  in  follicular  colitis  there  may  be  numerous  small  ulcers  where 
melsena  has  never  occurred. 

I   have   seen   some   marked   examples   of   true   dysentery  in   young- 
children  who  began  to  suffer  after  returning  to  England  from  the  East 


64         DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

Indies  where  they  had  recently  had  malarial  fever,  but  besides  the  fact 
that  in  some  instances  such  attacks  occurred  in  several  members  of  the 
family  of  various  ages  there  was  nothing  to  mark  the  individual  cases 
from  those  of  ordinary  severe  colitis.  A  remarkable  series  of  cases 
of  what  was  symptomatically  acute  dysentery  was  admitted  into  Shad- 
Avell  Hospital  in  the  summer  of  1890.  These  four  patients  varied  in 
age  from  1 J  to  8  years,  and  their  father  was  similarly  affected.  All  the 
cases  occurred  between  August  17  and  September  18.  The  father  and 
the  youngest  child  died.  In  all  the  symptoms  began  with  much  abdo- 
minal pain,  diarrhoea  and  tenesmus,  followed  by  the  passage  of  "blood 
and  slime "  and,  in  the  later  stage,  of  shreddy  material  or  obvious 
sloughs  with  no  faeces.  In  most  there  was  vomiting  at  the  outset,  in 
the  elder  ones  shivering,  and  in  all  rapid  wasting.  Convalescence  was 
very  slow  in  those  who  recovered.  Inquiry  revealed  no  dietetic  cause, 
but  the  father  discovered  a  much  decomposed  rat  in  the  cistern.  The 
mother  who  did  not  drink  water,  and  three  other  children  who  did,  were 
not  affected.  In  the  fatal  case  examined  in  hospital  marked  ulcera- 
tion and  sloughing  patches  were  found  along  the  whole  of  the  large 
intestine. 

In  considering  melcena  as  a  symptom  of  intestinal  disease  we  must 
remember,  besides  the  above-mentioned  causes,  both  tubercular  ulcera- 
tion presently  to  be  mentioned,  enteric  fever  and,  though  it  is  very  rare, 
ulceration  of  the  duodenum,  one  instance  of  which  I  have  seen  in  the 
practice  of  my  colleague  Dr.  Sturges.1  The  symptoms  in  this  case 
were  at  first  chiefly  those  of  vomiting  and  diarrhoea,  but  some  blood 
was  passed  per  anum  just  before  death.  Two  ulcers  were  found,  one 
of  which  had  perforated  close  to  the  pylorus,  and  there  was  a  closely 
neighbouring  circular  patch  of  capillary  haemorrhage  suggesting  the  first 
stage  of  these  ulcers.  Melaena  is  also  a  prominent  symptom  of  great 
diagnostic  import  in  intussusception,  results  often  from  a  polypus  in 
the  rectum  especially  during  or  after  defalcation  and  frequently  with 
associated  diarrhoea,  and  may  accompany  simple  prolapse  of  the  bowel. 

The  treatment  of  cases  of  enteritis  is  practically  included  in  a  great 
degree  under  that  of  severe  gastro-intestinal  disorder  already  dealt  with. 
"We  must  rely  chiefly  on  the  blandest  diet,  on  the  continued  use  of 
bismuth  and  opium,  and  on  protracted  cautiousness  against  possibly 
irritating  articles  of  food,  such  as  fruit  and  vegetables,  even  long  after 
convalescence  has  been  apparently  established.  In  proportion  as  there 
is  good  evidence  of  marked  intestinal  inflammation  or  ulceration,  or,  in 
other  words,  the  more  confident  our  diagnosis  is,  the  greater  care  we 
must  exercise ;  for  such  lesions  are  slow  to  heal  and  quick  to  relapse. 

Even  in  true   dysentery  and  symptomatically  allied  cases,  whether 

1  Reported  by  Dr.  Hebb  in  vol.  vii.  (1891)  of  the  Westminster  Hospital  Reports. 


GASTRIC  AND  INTESTINAL  DISEASE.  65 

acute  or  chronic,  I  believe  that  bismuth  in  large  closes  and  opium  are, 
like  the  well-accredited  ipecacuanha  powder,  among  the  best  remedies. 
Starch  and  opium  and  other  astringent  enemata  are  sometimes  very 
useful.  Large  injections  of  a  solution  of  silver  nitrate,  half  a  grain  to 
the  ounce,  have  also  been  recommended  in  adult  cases  and  may  well 
be  tried,  though  I  have  known  relapse  occur  soon  in  two  instances 
which  had  been  regarded  as  cured  by  this  method. 

In  treating  nielaena  as  such  we  must  have  due  regard  to  its  probable 
cause.  If  associated  with  hasmatemesis  local  treatment  will  probably 
be  useless. 

The  blood  which  comes  from  local  lesions  may  be  bright  or  dark 
according  to  the  seat  and  nature  of  the  mischief,  and  mixed  or  unmixed 
with  fasces.  In  intussusception  and  rectal  polypus  the  blood  is  usually 
red,  in  ulceration  higher  up  it  is  mostly  dark.  In  every  case  of  gastric 
or  intestinal  haemorrhage  a  local  source  must  be  carefully  searched  for 
before  making  any  definite  diagnosis  from  inference  alone.  The  rectum 
should  always  be  examined  with  the  finger.  I  once  saw  post-mortem 
in  a  case  of  enteric,  fever,  where  death  occurred  a  few  days  after  very 
severe  haemorrhage  from  the  anus,  two  deep  ulcers  a  little  above  the 
sphincter  which  were  the  undoubted  source  of  the  blood.  Ulceration 
elsewhere  was  slight  and  quite  superficial.  The  haemorrhage  here  might 
possibly  have  been  checked  by  local  treatment  had  the  rectum  been 
examined. 

In  the  severe  forms  where  no  local  cause  can  be  detected  or  reached 
an  ice-bag  should  be  applied  to  the  abdomen  and  small  quantities  of  iced 
milk  given  by  the  mouth.  The  child  should  at  the  same  time  have 
small  doses  of  alcohol.  It  is  useless  in  severe  cases  to  waste  time  over 
the  trial  of  styptics  given  by  the  mouth,  their  action  being  at  the  best 
highly  uncertain ;  but  the  subcutaneous  injection  of  ergotine  from 
\  to  h  grain  or  more  may  be  always  practised.  The  same  treatment 
is  applicable  to  all  cases  with  similar  symptoms  whatever  their  cause 
may  be.  Whenever  examination  detects  local  disorder  local  treatment 
is  necessary,  such  as  the  removal  of  a  polypus,  or  the  injection  of  some 
astringent  remedy  as  starch  and  opium  or  a  solution  of  nitrate  of  silver 
into  a  rectum  which  is  the  subject  of  ulceration  or  severe  catarrh. 

Tubercular  Disease  of  Intestines. 

In  all  chronic  and  obstinate  cases  of  diarrhoea  in  children,  especially 
when  accompanied  by  daily  remittent  pyrexia,  tubercular  ulceration 
must  be  suspected  and  careful  search  made  by  observation  and  inquiry 
for  any  corroborative  evidence  of  this  mode  of  causation.  In  infants 
under  three  months  old  tubercular  disease  of  the  intestines  and  indeed 

E 


66        DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

of  the  abdomen  generally  is  not  frequent.  After  this  age  it  becomes 
more  common  but  most  cases  occur  after  the  second  year.  Tubercular 
mesenteric  glands  usually  coexist  with  tuberculosis  of  the  bowel,  but 
either  condition  may  be  found  alone.  In  a  large  majority  of  cases  there 
is  clinical  evidence  of  tubercle  elsewhere,  especially  in  the  lungs.  Out 
of  400  cases  of  tuberculosis  I  found  but  12  per  cent,  clinically  regis- 
tered as  "  abdominal "  and  most  of  these  had  peritonitis  either  with  or 
without  intestinal  ulceration.  It  must  never  be  forgotten  that  tuber- 
cular ulceration  of  intestine  is  by  no  means  always  marked  by  diarrhoea. 
I  have  seen  many  cases  with  absolutely  no  diarrhoea  where  intestinal 
and  other  tubercle  was  proved  to  be  very  extensive.  Tubercular  disease 
of  the  intestine,  but  especially  when  there  is  diarrhoea,  is  apt  to  be  ac- 
companied by  abdominal  pain  some  time  after  feeding,  and  the  motions 
are  very  offensive,  brown  and  watery.  Frequently  there  is  more  or  less 
admixture  of  blood  with  the  faeces.  There  is  very  often  some  tender- 
ness and  much  peristalsis  visible  through  the  abdominal  walls,  due 
probably  to  the  adhesion  of  coils  of  intestine  ;  and  mostly,  though  by 
no  means  always,  some  rise  of  temperature.  Tubercular  ulceration  is 
seen  mainly  in  the  ileum  but  may  be  much  more  extensive.  It  is  recog- 
nised by  its  usual  character  of  caseation  often  accompanied  by  gray 
granulations.  The  ulcers  may  be  deep  but  seldom  penetrate  to  the 
serous  surface.  Rarely  they  cause  contraction  of  the  gut  by  cicatri- 
sation. In  almost  all  cases  tubercle  elsewhere  is  found  post-mortem 
whether  detectable  or  inferable  during  life  or  no,  and  even  if  the  lungs 
escape  the  bronchial  glands  are  caseous. 

The  diagnosis  of  the  tubercular  nature  of  intestinal  disorder  pointing 
to  ulceration  depends  mainly  on  the  discovery  of  evidence  of  tubercular 
disease  elsewhere,  especially  of  the  mesenteric  glands,  peritoneum  or 
respiratory  organs.  Persistently  remittent  temperature  is  highly  corro- 
borative of  the  suspicion,  but  we  must  remember  that  in  severe  cases, 
while  the  disease  is  confined  or  mainly  confined  to  the  abdomen,  the 
temperature  may  be  normal.  Although  some  examples  of  chronic  tuber- 
cular ulceration  may'sometimes  be  at  first  unattended  by  marked  wasting 
the  co-existence  of  such  wasting  with  other  symptoms,  especially  when 
there  is  little  diarrhoea,  points  strongly  to  tuberculosis.  In  many  cases 
the  suspicion  of  tuberculosis  amounts  almost  to  a  certainty  when  anaemia 
and  wasting  progress  and  predominate  over  all  local  symptoms.  It  must 
however  be  recognised  that  in  spite  of  all  care  tuberculosis  is  not  seldom 
erroneously  diagnosed  on  the  ground  of  both  intestinal,  thoracic  and 
even  cerebral  symptoms  suggestive  of  tubercle,  and  that  tuberculosis 
especially  in  the  absence  of  diarrhoea  is  often  found  post-mortem  when 
least  suspected. 

There  would  seem  to  be  little  doubt  from  clinical  and  post-mortem 


CONSTIPATION.  67 

experience  together  that  tuberculosis  frequently  supervenes  on  previous 
inflammatory  conditions  of  the  intestines,  especially  those  of  longstanding. 
I  have  over  and  over  again  observed  the  late  epiphenomena  of  pyrexia, 
of  pulmonary  trouble,  and  sometimes  of  peritonitis  in  cases  long  under 
observation  for  chronic  diarrhoea  with  probable  intestinal  catarrh  or 
simple  ulceration,  where  the  post-mortem  examination  has  established 
intestinal  and  general  tuberculosis. 

All  cases  of  suspected  ulceration  of  the  bowel  should  be  sedulously 
treated  according  to  the  principles  previously  laid  down — both  local  and 
general  measures  being  taken — regardless  of  their  possible  or  probable 
tubercular  origin.  It  is  perhaps  only  in  those  cases  where  rapid  wasting, 
continued  pyrexia  and  the  positive  evidence  of  tubercle  elsewhere  exist 
that  we  are  justified  in  giving  a  hopeless  forecast.  I  have  too  often  been 
agreeably  surprised  at  the  recovery,  after  protracted  care  and  nursing,  of 
intestinal  cases  which  I  have  regarded  as  almost  certainly  tubercular  to 
feel  able  to  give  any  hard  and  fast  rules  for  diagnosis  and  prognosis,  or 
any  better  advice  than — Persevere  in  treatment. 


CHAPTER    VI. 

CONSTIPATION. 

By  this  term  I  would  designate  insufficient  evacuation  of  the  bowels  as 
evidenced  by  one  or  more  of  the  following  symptoms  : — pain  or  local  dis- 
comfort during  defsecation,  prevailing  abdominal  distension  or  discomfort 
with  small  stools  not  necessarily  either  hard  or  very  infrequent,  or  certain 
symptoms  of  ill-health  concurring  with  markedly  defective  bowel  action. 
Merely  infrequent  defaecation  is  physiological  with  many  children,  and 
when  unattended  by  any  local  or  general  signs  or  symptoms  of  disorder 
is  neither  to  be  dreaded  nor  treated.  Deficient  muscular  action  of  the 
intestines  in  weakly  children  contributes  to  infrequent  defsecation,  and 
completely  digestible  food,  especially  milk,  will  often  occasion  scanty  and 
dry  fseces. 

The  chief  immediate  causes  of  constipation  are  imperfect  expulsive 
action  of  the  intestines,  either  from  inherent  general  weakness  or  defec- 
tive stimulation,  or  some  obstruction  in  their  course.  I  shall  speak 
here  mainly  of  those  cases  which  are  unconnected  with  malformation 
or  mechanical  lesion,  but  would  remark  in  passing  that  there  are  in  all 
probability  some  cases  which  are  symptomatically  chronic  constipation 
but  really  due  to  the  congenital  narrowing  of  the  intestine  at  some  point 


68        DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

— a  condition  which  is  not  infrequently  found  post-mortem  when  it  has 
never  been  suspected.  I  have  met  with  a  few  cases  which  I  believe  to 
be  of  this  description  and  it  is  probable  that  such  cases  may  be  more 
frequent  than  demonstrable.  The  following  appears  to  be  referable  to 
this  category.  A  girl  of  nine  years  old  came  under  observation  with 
a  history  of  having  suffered  during  most  of  her  life  from  abdominal 
discomfort  apparently  connected  with  the  fact  that  she  had  been  for 
an  equal  time  subject  to  periods  of  faecal  retention  of  two  or  three 
Aveeks'  duration,  separated  by  the  occurrence  of  one  and  sometimes  of 
two  very  large  motions.  This  condition  resisted  all  treatment,  even 
frequently  repeated  large  enemata  seeming  to  be  of  use  only  about  the 
times  when  the  motions  were  in  the  habit  of  being  spontaneously  passed. 
The  act  of  defaecation  was  rendered  easier  and  much  less  painful  but 
was  very  slightly  anticipated  by  enemata,  a  certain  amount  of  pressure 
from  faecal  accumulation  appearing  to  be  always  necessary  for  any  passage 
.to  take  place  through  the  presumably  narrowed  part  of  the  gut. 

Some  infants  have  deficient  intestinal  action  from  birth,  even  when 
breast-fed  ;  the  stools  are  lumpy  and  hard,  passed  with  straining,  often 
very  pale  or  almost  colourless  like  the  stools  of  jaundice,  and  sometimes 
slightly  streaked  with  blood  from  small  erosions  within  the  anus  pro- 
bably caused  by  the  hardened  faeces.  Now  constipation  in  infancy,  a 
period  when  the  bowels  are  as  a  rule  frequently  evacuated,  should  always 
be  noted.  Its  cause  is  often  not  to  be  detected,  for,  although  there  may 
be  sometimes  signs  of  catarrhal  derangement  of  the  intestines,  or  of  defi- 
cient action  of  the  liver  or  possibly  of  the  pancreas  after  such  time  as  the 
pancreatic  secretion  is  usually  well-established,  in  very  many  cases  the 
only  symptom  is  the  difficult  or  painful  passage  of  hard  dry  faeces,  and 
the  dryness  of  the  faeces  is  by  no  means  always  explicable  by  drain  of 
fluid  from  skin  or  kidneys.  Unquestionably  a  cbange  in  the  diet  may 
indicate  the  cause  while  working  the  cure  of  constipation,  and  such 
change  should  always  be  tried.  Often  the  tendency  remains  until  the 
child  takes  active  exertion  and  a  mixed  diet,  and  is  probably  due  to 
deficient  nerve  force  causing  intestinal  atony.  The  frequency  of  con- 
stipation as  a  symptom  of  brain-disease,  as  in  tubercular  meningitis,  must 
be  remembered  in  this  context,  as  also  its  very  general  concurrence  with 
melancholia,  hypochondriasis  and  other  evidences  of  a  disordered  nervous 
system  in  adult  life.  In  many  apparently  gastric  attacks  in  nervous 
children,  with  or  without  fever,  as  elsewhere  noted,  constipation  is  often 
prominent.  When  local  and  dietetic  causes  can  be  excluded  by  careful 
examination  and  reflection  over  the  case  we  must  trust  to  time  and 
general  tonic  measures,  with  such  stimulation  by  food  as  may  be  con- 
sistent with  the  child's  age,  to  aid  in  the  cure.  Frequent  and  prolonged 
kneading  of  the  abdomen  with  the  oiled  hand  is  often  very  useful,  and 


CONSTIPATION.  69 

help  is  sometimes  afforded  by  occasional  small  suppositories  of  snap  or 

injections  of  cold  water,  or  half  a  drachm  of  glycerine.  In  infants  there 
is  little  advantage  in  the  use  of  medicines  which  should  he  always 
avoided  if  possible.  Sometimes  however  a  purge  will  be  found  neces- 
sary when  distension  or  discomfort  is  great.  The  sluggishness  of  the 
bowel  may  perhaps  be  lessened  by  the  systematic  administration  of  liquor 
strychnia}  or  tincture  of  belladonna.  There  is  at  least  a  considerable 
amount  of  authority  in  favour  of  this  treatment,  but  I  have  seen  little 
or  no  result  either  in  children  or  adults  with  habitual  constipation  from 
the  persevering  use  in  many  cases  of  such  remedies,  although  in  two 
instances,  in  an  adult  and  a  child  respectively,  of  marked  constipation 
with  flatulent  distension  I  have  observed  a  rapid  diminution  of  the 
abdominal  swelling  with  expulsion  of  gas  soon  after  the  administration 
of  one  or  two  full  doses  of  strychnia.  Occasionally  in  infants  constipa- 
tion is  due  entirely  to  irritation  of  the  anus  caused  by  painful  fissures 
and  inducing  contraction  of  the  sphincter.  Laxatives  and  local  treatment 
by  nitrate  of  silver  or  some  other  astringent,  or  the  application  of  cocaine, 
or,  failing  these  remedies,  surgical  treatment  of  the  fissure  must  then  be 
resorted  to. 

Apart  from  these  instances  of  infantile  affection  which  frequently  lead 
to  no  further  symptoms  and  do  not  necessarily  interfere  with  health  it 
may  be  said  that  constipation  at  all  ages  owns  various  causes,  and  that 
each  case  must  be  studied  and  treated  by  itself.  The  chief  causes,  out- 
side general  debility,  nervous  or  otherwise,  are  want  of  exercise,  too 
unstimulatmg  or  easily  digestible  or  monotonous  diet,  and  overfeeding 
with  neglect  of  regular  times  for  defalcation.  A  diet  largely  composed 
of  milk  greatly  favours  constipation,  as  also  does  prolonged  rest  in 
bed.  This  is  seen  markedly  in  most  cases  of  convalescence  from  acute 
diseases,  especially  enteric  fever.  Sometimes  constipation  of  consider- 
able persistence  is  observed  after  severe  attacks  of  diarrhoea  or  the 
frequent  and  unnecessary  use  of  purgative  drugs.  In  these  latter  cases 
time  and  a  mixed  diet  are  at  once  the  most  rational  and  successful 
medicines. 

Habitual  or  marked  constipation  at  any  period  of  infancy  or  child- 
hood may  be  accompanied  by  local  symptoms  of  more  or  less  severity  or 
general  ill-health,  or  a  combination  of  these  conditions.  When  constipa- 
tion from  any  cause  is  marked  or  lasting  there  may  be  distension  of  the 
abdomen  with  tenderness,  giving  rise  to  a  suspicion  of  peritonitis.  Great 
loading  of  the  loAver  bowel  with  faeces  may  be  attended  by  the  daily  or 
more  frequent  passage  of  small  liquid  stools,  sometimes  amounting  to 
what  may  be  called  diarrhoea.  In  their  lesser  degrees  these  cases  are 
not  rare.  An  extreme  example,  ending  fatally,  I  once  saw  in  a  boy  about 
three  years  old  who  had  been  medically  treated  without  examination  for 


yo        DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

some  months  for  diarrhoea  from  which  he  had  heen  suffering  for  over  a 
year.  He  was  admitted  into  hospital  in  a  state  of  collapse  with  much 
pain  and  enormous  distension  of  the  ahdomen,  and  died  suddenly  a  few 
hours  afterwards.  The  howel  was  found  post-mortem  to  he  greatly 
stretched  and  full  of  a  rock-like  mass  of  hard  gray  crystalline  faeces 
which  nearly  filled  an  ordinary  hucket.  In  the  mass  there  was  a 
small  sinuous  channel  through  which  the  liquid  evacuation,  disastrously 
diagnosed  and  treated  as  "  diarrhoea,"  had  heen  constantly  trickling. 
The  diaphragm  was  pushed  far  up  into  the  thorax,  the  hoy  apparently 
dying  from  cardiac  paralysis.  Eustace  Smith  relates  a  very  similar  case. 
The  lesson  is  here  learned  of  making  a  thorough  physical  examination  of 
all  cases  of  reported  diarrhoea  as  well  as  of  constipation  hefore  instituting 
a  course  of  treatment.  Constipation  per  se  should  never  he  fatal  either 
directly  or  indirectly,  nor  give  rise  to  serious  symptoms.  Complete 
occlusion  of  the  intestine  and  typhlitis  leading  to  perityphlitis  or  general 
peritonitis  are  said  hy  various  authorities  to  be  the  occasional  or  even 
frequent  results  of  neglected  constipation.  These  events  are  neverthe- 
less exceedingly  rare  or,  in  my  opinion,  altogether  apocryphal.  Con- 
stipation preceding  typhlitis  is  not,  as  often  taught,  the  rule,  but  the 
exception,  and  their  occasional  connection  is,  I  think,  merely  accidental. 
As  a  result  however  of  typhlitis  secondary  to  affection  of  the  vermi- 
form appendix  constipation  is  often  marked,  and  sometimes  favours  the 
mistaken  diagnosis  of  occluded  bowel. 

The  symptoms  other  than  local  which  may  accompany  habitual  con- 
stipation are  numerous  and  often  indefinite  and  require  much  diagnostic 
caution  before  being  referred  to  any  one  cause.  Many  of  the  ailments 
attributed  to  constipation  are  doubtless  part  of  the  original  malady  out 
of  which  the  constipation  arises,  as  is  exemplified  in  some  neurotic 
cases,  and  in  rapidly  developed  anaemia.  Decided  rise  of  temperature  is  a 
frequent  accompaniment  of  a  loaded  bowel.  Not  only  in  enteric  fever 
both  during  its  course  and  in  convalescence,  but  also  in  apparently  simple 
cases,  there  is  abundant  clinical  evidence  of  raised  temperature  resulting 
from  constipation.  From  among  numerous  examples  of  this  in  my  note- 
books I  give  the  following  extraordinary  instances  of  two  young  children 
who  were  admitted  at  different  times  into  hospital  with  great  abdominal 
distension  and  pain,  and  temperatures  of  1070  and  108°  respectively,  in 
both  of  which  all  these  symptoms  rapidly  and  permanently  disappeared 
after  the  evacuative  action  of  simple  enemas.  I  am  inclined  to  refer 
such  cases  as  this,  with  other  instances  I  have  seen  of  abdominal  pain  at 
all  ages  accompanied  by  high  temperature  of  short  duration,  to  a  ner- 
vous origin  through  impressions  made  on  the  abdominal  sympathetic,  in 
view  of  the  suddenness  of  the  rise  of  temperature  and  the  equal  sudden- 
ness of  its  fall  with  coincident  evacuation  of  the  bowel.      In  more 


CONSTIPATION.  7  I 

chronic  cases  of  constipation  some  pyrexia  may  possibly  be  due  to  the 
retention  of  excrementitious  matter  or  auto-infection.  For  the  rest,  as 
in  adults,  so  in  children,  habitual  constipation  is  often  accompanied,  be 
it  causally  or  coincidentally,  by  a  sallow  or  pale  complexion,  by  languor, 
slow  circulation,  loss  of  appetite,  foul  breath,  troubled  sleep  or  headaches  ; 
and  there  are  some  cases  where  such  symptoms  disappear  if  the  constipa- 
tion be  cured  by  diet  or  drugs.  Kecurrent  sick-headache,  or  migraine — 
a  very  common  disorder  of  childhood  and  almost  always  the  outcome 
of  a  special  or  general  neurosis — is  not  seldom  attended  by,  and  in  my 
opinion  most  erroneously  explained,  both  popularly  and  professionally, 
by  constipation,  the  relief  of  which  in  no  way  lessens  the  frequency  or 
duration  of  the  other  symptoms.  I  am  aware  that  many  authorities 
think  that  constipation  in  children  is  much  more  frequent  and  entails 
many  more  untoward  consequences  than  I  have  above  referred  to.  I 
have  only  spoken  from  my  own  experience.  For  detailed  account  of 
different  views  I  would  refer  to  an  exhaustive  article  by  Dr.  W.  Earle 
in  Keating's  Cyclopaedia. 

The  general  treatment  of  constipation,  after  a  careful  inquiry  into  its 
most  probable  causation,  is  rather  hygienic  and  dietetic  than  medicinal. 
In  all  cases  the  abdomen  must  be  examined,  when  scybala  may  often 
be  felt,  and  the  rectum,  if  found  by  the  finger  to  be  loaded,  should  be 
evacuated  by  an  enema  or  other  means.  In  recent  acute  cases  accom- 
panied by  abdominal  pain  or  other  urgent  symptoms  rest,  opium  and 
expectance  are  the  next  steps,  as  will  be  further  mentioned  under  the 
head  of  obstruction.  We  must  always  remember  that  there  is  no  such 
thing  as  acute  constipation  requiring  purgation  for  the  purpose  of  avoid- 
ing a  dangerous  event.  Constipation,  with  any  other  symptom  of  recent 
occurrence  should  never  be  treated  as  such,  and  occurring  alone  may  be 
safely  and  wisely  neglected  for  a  while.  In  the  absence  of  vomiting  or 
other  symptoms  of  obstruction  and  especially  of  intussusception,  even 
when  there  is  pyrexia,  distension  of  the  abdomen  with  a  history  of 
constipation  sometimes  indicates,  as  I  have  above  shown,  evacuation  by 
enema.  Even  if  there  be  mechanical  obstruction  one  effort  with  this 
object  will  probably  be  harmless.  General  directions,  however,  as  to  the 
due  diagnosis  of  such  cases  cannot  be  given. 

In  chronic  constipation  the  diet  must  be  first  attended  to.  I  have 
already  indicated  the  general  treatment  of  infantile  constipation  which 
rarely  requires  aperients.  But,  if  there  be  reason  to  believe  from  the 
concurrence  of  gastric  disorder  or  the  appearance  of  the  stools  that  a 
catarrhal  condition  is  present,  the  infant's  diet  should  be  regulated 
accordingly,  and  milk  and  farina  should  for  a  while  be  given  sparingly 
or  not  at  all.  Small  doses  of  sodium  bicarbonate  and  rhubarb  will  then 
often  be  found  useful  for  a  few  days.     If  the  supposed  catarrhal  condition 


72         DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

of  the  intestine  be  due  to  chill  either  as  a  symptom  per  se,  or  be  a 
part  of  more  widespread  evidence  of  cold,  warm  clothing  to  the  body 
and  especially  to  the  abdomen  is  certainly  indicated.  At  all  events,  how- 
ever doubtful  the  exact  diagnosis  may  be,  chronic  constipation  is  so  often 
attended  by  sluggish  circulation  that  due  attention  should  always  be 
given  to  this  point.  "Whether  or  no  deficient  fluid  be  the  cause  of  con- 
stipation a  free  supply  of  pure  water  may  always  be  tried  in  cases  where 
the  stools  are  dry  and  hard ;  it  is  at  least  a  good  stimulant  to  a  torpid 
intestine.  With  older  children  a  daily  regular  evacuation  after  break- 
fast or  an  attempt  at  it  should  be  insisted  on  both  as  a  preventive  and 
remedial  measure,  many  troublesome  cases  of  constipation  being  initiated 
by  neglect  of  this  custom  otherwise  so  important  in  civilised  society.  A 
mixed  diet  with  plenty  of  vegetable  and  fruit  and  whole-meal  bread  is 
necessary,  and  exercise  with  gymnastics  suited  to  the  age  is  to  be  enforced. 
All  hygienic  measures  should  be  taken  before  resorting  to  drugs,  which 
are,  however,  in  some  cases  required  not  only  to  remove  the  abdominal 
discomfort  that  sometimes  results  from  a  loaded  bowel  but  also  to 
prevent  the  possible  ulterior  symptoms  of  ill-health  which  have  been 
mentioned.  Merely  purgative  drugs,  however  necessary  they  sometimes 
may  be,  are  but  temporarily  stimulant ;  they  should  be  used  in  the  smallest 
doses  which  have  the  desired  effect,  and  as  seldom  as  possible.  I  believe 
that  senna  and  sulphur,  in  the  form  of  confection,  or  aloes  are  as  good 
remedies  as  any,  and  cascara  is  often  very  effective.  I  have  already  said 
that,  in  spite  of  very  many  cases  of  habitual  constipation  in  children 
being,  in  my  opinion,  primarily  referable  to  nervous  causes  and  not  to 
local  disorder  or  disease  of  the  alimentary  canal,  I  have  usually  been 
disappointed  with  the  much-quoted  action  of  strychnia  and  belladonna 
so  widely  used  in  this  affection.  It  is  of  the  highest  importance  to 
attend  to  all  concomitant  symptoms  in  cases  of  chronic  constipation.  I 
have  had  far  greater  success  from  the  prescription  of  exercise,  simlight, 
fresh  air,  arsenic,  cod-liver  oil  and  iron,  and  the  proscription  of  prolonged 
rest,  either  in  bed  or  out  of  it,  than  from  any  systematic  course  of  special 
drugs.  There  is  in  fact  but  little  peculiar  in  the  constipation  of  child- 
hood ;  it  has  much  the  same  clinical  aspect  as  that  of  adults.  There  are 
few  affections  where  the  therapeutist's  temptation  is  so  great  to  achieve 
an  easy  although  but  temporary  success  by  symptomatic  treatment  while 
neglecting  the  causal  conditions  of  the  disorder. 


ENTESTINAL  OBSTRUCTION.  73 


CHAPTER   VI J. 
INTESTINAL  OBSTRUCTION. 

The  subject  of  mechanical  obstruction  of  the  bowels  in  young  children, 
apart  from  the  faecal  accumulation  dealt  with  in  the  last  chapter,  practi- 
cally resolves  itself  into  that  of  Intussusception.  Occasionally  we 
meet  with  other  occlusions,  such  as  partial  or  complete  congenital 
stricture  which  may  sometimes  be  due  to  foetal  peritonitis,  hernias, 
strangulations  from  peritoneal  bands  or  obstruction  from  malignant 
or  other  tumours,  but  these,  with  the  exception  of  complete  congenital 
atresia,  present  nothing  special  to  childhood.  It  must  never  be  for- 
gotten that  symptoms  of  acute  peritonitis  from  whatever  cause  arising 
very  often  exactly  simulate  those  of  intestinal  obstruction. 

Intussusception  is  most  common  in  infancy  and  early  childhood  and  at 
this  period  generally  consists  in  the  invagination  to  a  greater  or  less 
extent  of  the  lower  part  of  the  ileum  and  ileo-caecal  valve  within  the 
colon,  the  cases  of  engagement  of  the  small  intestine  alone  being  mostly 
confined  to  later  childhood  and  adult  life.  The  comparative  frequency 
of  the  involvement  of  the  caecum  in  infancy  has  been  referred  to  its  looser 
connections  in  the  iliac  fossa  at  this  age.  The  anatomy  of  intussusception 
is  amply  described  in  the  general  text-books.  I  need  but  mention  here 
that  small  and  multiple  intussusceptions,  easily  reducible,  are  frequently 
found  post-mortem,  and  doubtless  take  place  during  the  act  of  dying. 
Those  which  cause  symptoms  are  larger,  at  least  two  or  three  inches  in 
length,  and  may  involve  several  feet  of  gut  and  be  felt  in  the  rectum 
or  even  protrude  from  the  anus.  No  exciting  cause  for  the  disordered 
peristalsis  which  must  precede  this  affection  can  be  demonstrated  in  most 
instances.  Eustace  Smith  quotes  cases  occurring  soon  after  a  fall,  and  I 
have  seen  two  instances  of  this  possibly  causal  connection. 

Intussusception  leads  to  partial  or  complete  obstruction  of  the  canal  and 
inflammatory  strangulation  of  the  two  contained  layers  of  bowel.  Some- 
times ulceration  takes  place  with  perforation  through  the  outer  layer 
into  the  peritoneal  cavity,  or  there  may  be  general  peritonitis  without 
perforation.  The  invaginated  part  may  be  so  gripped  as"  to  become 
quickly  gangrenous  and  may  be  discharged  through  the  anus.  In  some 
cases  with  firm  adhesions  recovery  takes  place,  the  external  layer  of 
bowel  forming  a  tube  continuous  with  the  unaffected  part  above  the 
lesion. 


74         DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

Clinically,  cases  of  intussusception  may  be  divided  into  two  classes, 
those  where  the  diagnosis  is  almost  certain,  and  those  where  it  is  only 
probable.  The  clearest  cases  are  those  where  the  child  shows  sudden 
evidence  of  abdominal  pain,  screaming  and  drawing  up  the  legs.  The 
pain  comes  on  paroxysmally,  vomiting  follows  and  is  repeated,  and 
there  is  straining  with  the  passage  of  faeces,  if  the  bowel  below  the 
obstruction  be  not  already  empty,  or  with  the  passage  of  mucus  or 
blood.  There  is  generally  no  marked  abdominal  tenderness  at  the 
outset,  and  deep  pressure  can  be  made  without  finding  any  tumour. 
Later  on  a  tumour,  tender  on  pressure,  may  sometimes  be  felt  externally, 
if  the  abdomen  be  not  distended,  and  in  the  course  of  time  a  soft  elastic 
swelling  may  be  detected  by  the  finger  in  the  rectum.  Whether  or  no 
there  be  one  or  more  evacuations,  liquid  or  otherwise,  at  the  outset,  con- 
stipation soon  sets  in.  The  child  is  very  restless  and  may  not  sleep  at 
all.  If  the  symptoms  do  not  soon  remit  with  or  without  treatment  they 
rapidly  increase.  Coils  of  dilated  intestine  are  often  seen  through  the 
walls,  collapse  takes  place  with  small  frequent  pulse  and  cold  extremities, 
and  the  child  dies  in  from  four  to  eight  days  from  the  outset  of  the 
attack.  The  temperature  may  remain  normal,  or  may  rise  several 
degrees,  especially  when  there  is  peritonitis,  until  it  falls  at  the  period 
of  collapse.  The  more  complete  the  strangulation  of  the  bowel  the  more 
rapid  is  the  course  of  the  case. 

Chronic  intussusception  of  very  various  duration  and  symptomatic 
character  may  take  place  in  childhood,  but  it  is  not  common  and  perhaps 
never  affects  infants.  It  is  marked  by  constipation  either  persistent 
or  intermittent  and  by  varying  distension  of  the  abdomen  with  peristalsis 
visible  through  the  abdominal  walls.  In  one  case  of  this  kind  where 
I  suspected  imperfect  bowel  obstruction  death  with  acute  symptoms 
took  place,  as  I  heard,  after  several  months.  The  peristaltic  action  was 
almost  continuously  visible  for  many  weeks.  Such  cases  are  generally 
fatal  in  the  long  run  and  are  as  a  rule  beyond  the  scope  of  other  than 
conjectural  diagnosis. 

Now,  abdominal  pain,  vomiting,  constipation  and  the  passage  of  blood 
from  the  anus  coming  on  in  a  previously  healthy  child  are  practically 
almost  pathognomonic  of  intussusception,  and  the  diagnosis  is  assured 
by  the  discovery  by  palpation  of  a  tumour,  especially  in  the  right  iliac 
region  or  in  the  rectum.  As  to  tumours  felt  externally,  their  diagnostic 
importance  varies  greatly.  In  the  absence  of  marked  symptoms  of 
obstruction  it  is  sometimes  exceedingly  difficult  to  distinguish  them 
from  accumulations  of  faeces.  I  have  known  a  case  where  there  were 
symptoms,  lasting  some  weeks,  of  constipation  and  occasional  passage 
of  bloody  mucus  with  the  scanty  faeces.  Complete  constipation  followed, 
with  sickness  for  some  days.     An  elongated  tumour  not  indented  by 


INTESTINAL  OBSTRUCTION.  7  5 

pressure  was  felt  in  the  region  of  the  descending  colon  but  no  blood 
was  seen  on  the  finger  after  rectal  examination.  The  boy,  aged  13, 
seemed  very  ill  and  in  abdominal  pain.  Two  copious  injections  of  the 
bowel  Avith  warm  water,  not  followed  by  any  faecal  discharge,  soon 
relieved  the  symptoms,  which,  however,  returned  and  were  relieved 
again  by  a  simple  enema.  The  tumour  may  be  felt  in  the  region  of 
either  the  ascending,  transverse,  or  descending  colon.  Authorities  differ 
as  to  its  most  frequent  position  but  the  question  is  I  think  of  but  little 
clinical  importance. 

The  following  case  which  is  typical  of  not  a  few  is  a  good  example  of 
what  I  have  called  the  group  of  probable  cases.  A  boy  of  four  years 
old,  previously  quite  well,  had  a  fall  on  his  head  on  the  evening  of 
July  16,  1 88 1,  and  seemed  much  collapsed  soon  afterwards.  He  was 
given  some  medicine,  vomited,  complained  of  much  pain  in  the  abdomen 
and  passed  a  few  loose  stools.  The  vomiting  continued,  with  great 
thirst,  until  admission  into  hospital  the  following  midday.  At  10  p.m. 
on  the  17th  vomiting  was  urgent  with  signs  of  collapse,  the  abdomen 
was  soft,  but  a  small  hardish  lump,  tender  on  pressure,  was  felt  near 
the  umbilicus.  There  had  been  no  motion  since  admission.  Nothing 
was  felt  in  the  rectum.  A  subcutaneous  injection  of  vjth  of  a  grain 
of  morphia  was  given,  and  iced  milk  in  small  quantities.  After  a  sleep 
of  several  hours  the  vomiting  returned.  A  simple  enema  (one  pint) 
brought  away  a  little  greenish  fluid  and  a  few  small  faecal  lumps.  In 
the  afternoon  of  the  18th  two  pints  of  soap  and  water  were  slowly 
injected  into  the  rectum,  the  boy  being  held  with  upraised  buttocks, 
and  the  abdomen  simultaneously  manipulated  by  pressure  directed  from 
the  groin  towards  the  umbilicus.  Much  of  the  fluid  was  retained.  The 
child  vomited  but  twice  during  the  night  and  the  next  day,  but  the 
pulse  remained  very  weak.  On  the  evening  of  the  19th  he  had  another 
morphia  injection.  After  vomiting  twice  more  on  the  20th  and  retain- 
ing some  iced  milk  given  by  the  mouth  he  passed  a  solid  but  unformed 
stool  in  the  evening,  the  lump  was  no  longer  felt,  and  he  recovered 
quickly.  This  case  may  be  put  down  by  some  to  faecal  obstruction, 
but  the  suddenness  of  its  onset  and  the  unformed  character  of  the  first 
stool  point  strongly  away  from  this  explanation.  The  temperature  was 
scarcely  above  normal  throughout.  In  another  instance  very  similar 
to  this,  where  recovery  made  the  diagnosis  doubtful,  the  return  of  the 
child  to  the  hospital  in  a  few  days  and  death  with  all  the  classical 
symptoms,  followed  by  a  post-mortem,  proved  the  existence  of  intus- 
susception. I  agree  with  Henoch  that  the  absence  of  a  palpable  tumour 
is  of  but  little  diagnostic  import,  for  the  abdomen  is  frequently  much 
distended  when  the  case  is  first  seen  and  it  is  but  seldom  that  anything 
can  be  felt  in  the  rectum  during   the   early  stage  of  the  affection.     1 


76         DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

have  been  sure  of  this  latter  sign  in  only  two  cases  both  of  which 
ended  fatally,  and  on  referring  to  a  consecutive  series  of  twelve  cases 
diagnosed  as  intussusception  by  various  members  of  the  staff  of  the 
Hospital  for  Children  I  found  that  in  none  of  the  six  cases  which 
recovered  after  injection  was  intra-rectal  tumour  reported,  while  its 
absence  was  specially  noted  in  four.  '  The  tumour  caused  by  accumu- 
lated faeces  can  usually  be  indented  by  pressure,  and  the  case  is  charac- 
terized neither  by  sudden  onset  nor  discharge  of  blood.  Peritonitis 
very  often  causes  symptoms  of  obstruction  but  not  of  intussusception. 
The  onset  of  vomiting  may  here  be  sudden  but  there  is  usually  early 
distension  of  the  abdomen  with  much  tenderness  and  pyrexia. 

Cases  of  sudden  and  repeated  vomiting  at  the  onset  of  acute  febrile 
disease  with  constipation  are  occasionally  diagnosed  as  obstruction.'  The 
two  following  instances  which  I  have  seen  of  pneumonia  being  taken 
and  in  one  case  treated  for  obstruction  are  of  sufficient  rarity  and  im- 
portance to  be  quoted.  The  first  was  a  boy  of  six  years  old  who 
was  admitted  to  hospital  with  a  history  of  repeated  vomiting  of  yellow 
liquid  for  four  days  beginning  after  a  meal  of  boiled  pork.  The 
bowels  had  not  acted  for  six  days.  Three  days  before  admission  he 
complained  of  pain  with  abdominal  tenderness,  but  there  was  no  disten- 
sion. On  the  day  before  admission  his  vomit  was  said  to  smell  like 
motions.  The  next  day  the  vomiting  ceased.  He  had  five  enemata 
by  medical  advice  with  no  result.  On  admission  the  temperature 
was  over  102° ;  there  were  signs  of  bronchitis  but  no  pulmonary 
dulness.  The  abdomen  was  distended  and  there  was  some  tenderness, 
but  nothing  was  felt  by  external  or  rectal  examination.  The  bowel  was 
ineffectually  inflated.  The  next  day  the  child  vomited  twice,  but  not 
faecally,  and  the  head  was  retracted.  A  gallon  of  tepid  water  Avas  in- 
jected, retained  for  a  while,  and  returned  slightly  discoloured.  The 
child  seemed  to  be  dying.  Abdominal  section  was  then  performed, 
everything  was  found  perfectly  normal,  and  four  ounces  of  liquid  fseces 
were  passed  from  the  anus  during  the  operation.  Two  days  afterwards 
the  child  died  with  peritonitic  symptoms  and  the  post-mortem  revealed 
recent  peritonitis  with  enlarged  mesenteric  glands  but  no  stricture  or 
intussusception.  There  was  however  double  pneumonic  consolidation, 
one  lung  being  in  the  stage  of  gray  hepatisation. 

The  second  case,  a  girl  of  4  J  years,  was  sent  by  medical  advice  to  West- 
minster Hospital  on  July  16,  1890,  as  intestinal  obstruction  demanding 
operation.  She  was  said  to  have  been  well  on  the  morning  of  the  14th. 
In  the  afternoon  she  looked  pale  and  ill,  went  to  sleep  for  an  hour, 
and  then  woke  up  with  abdominal  pain  and  vomited.  Very  frequent 
vomiting  with  pain  in  head  and  abdomen  continued  until  admission, 
following  always  on  attempts  to  eat  or  drink.     Between  the  attacks  of 


I NTEST I N  A I  i  0  BSTRUCTION.  7  7 

vomiting  the  child  was  very  drowsy.  .She  had  a  slight  cough  which  had 
lasted  some  months.  Previous  to  this  attack  she  had  had  some  diarrhoea, 
but  there  had  been  no  action  of  the  bowels  from  the  14th  to  admission. 
When  seen  in  hospital  she  was  much  exhausted,  the  temperature  was 
104.8,  pulse  138,  respirations  40,  and  the  face  was  flushed.  Nothing 
was  detected  on  examination  of  the  chest,  and  no  pain  was  complained 
of.  A  normal  action  was  induced  by  an  enema  which  was  easily 
administered.  Some  acute  febrile  disease,  probably  pneumonia,  was 
suspected  from  the  temperature  and  general  appearance  which  was 
unlike  that  of  abdominal  mischief,  and  nothing  was  discovered  by 
abdominal  or  rectal  examination.  The  temperature  and  pulse  remained 
high  with  no  further  action  of  the  bowels,  on  the  18th  signs  of  con- 
solidation at  the  left  apex  were  first  discovered,  and  at  midnight  on  the 
19th  there  was  a  critical  fall  of  temperature  with  sweating.  The  child 
was  well  and  up  on  the  23rd.  In  this  case  the  repeated  vomiting,  which 
is  exceptional  in  pneumonia,  and  the  suddenness  of  onset  with  abdominal 
pain  fairly  raised  a  suspicion  at  first  of  intestinal  trouble,  but  the  con- 
dition of  the  child  on  admission  rendered  this  diagnosis  at  that  time 
extremely  unlikely. 

A  careful  study  of  all  the  cases  of  intussusception  which  have  come 
under  my  notice  leads  me  to  believe  that  the  prognosis  is  generally 
grave  when  the  diagnosis  is  certain  and  especially  when  the  invagina- 
tion is  felt  in  the  rectum.  Yet  many  cases  recover  with  prompt  treat- 
ment. My  colleague  Mr.  Parker1  has  made  the  observation  from  his 
cases  that  absence,  or  slight  amount,  of  blood-discharge  from  the  anus, 
and  indeed  a  short  period  of  pain  or  vomiting  at  the  outset  followed  by 
a  time  of  comparative  comfort  are  by  no  means  necessarily  of  good  im- 
port, as  these  conditions  are  often  concurrent  with  rapid  gangrene  of  the 
intestine  leading  to  death  in  collapse  ;  while  a  free  discharge  of  blood 
signifies  by  itself  incarceration  rather  than  strangulation.  On  the  other 
hand  I  would  say  that  such  a  condition  as  causes  a  free  discharge  of 
blood  must,  if  persistent,  soon  become  one  of  strangulation  and  points 
to  prompt  remedial  interference.  It  may  I  think  be  said  that  the  cases 
which  may  recover  from  treatment  are  first,  those  where  with  initial 
pain  and  vomiting  and  obstinate  constipation,  with  or  without  a  tumour 
detectable  through  the  walls,  there  is  no  discharge,  or  but  slight,  of 
blood  from  the  anus  and  no  considerable  abdominal  distension,  and 
next  those  where  there  may  be  a  notable  amount  of  blood  passed  for  a 
while,  the  abdomen  being  likewise  undistended ;  while  the  gravest  of 
all  and  least  likely  to  recover  under  any  treatment  are  those  where,  with 
obstinate  constipation,  the  abdomen  is  distended  and  the  acute  symptoms 
of  pain  and  perhaps  vomiting  as  well  diminish  early  or  cease  altogether. 
1  Clinical  Society's  Transactions,  vol.  xxi. 


78         DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

Constipation  therefore  of  sudden  onset  attended  by  pain  or  vomiting  in 
a  previously  healthy  child  should  always  raise  the  suspicion  of  intus- 
susception, and  calls  for  early  treatment  without  waiting  for  that  ab- 
dominal distension  which  even  in  the  absence  of  any  palpable  tumour 
will  in  many  cases  clinch  the  diagnosis.  The  discovery  of  a  tumour  or 
the  discharge  of  blood  would  favour  this  decision  and  emphasise  the  need 
of  immediate  relief.  It  is  thus  clear  that  treatment  must  be  begun 
in  many  cases  before  the  diagnosis  is  settled ;  in  waiting  for  certainty 
the  chance  of  recovery  may  be  lost.  A  definite  case  untreated  and  of 
three  days'  standing  will  generally  die  whatever  is  done,  although  in 
exceptional  instances  there  may  be  recovery.  I  leave  out  of  considera- 
tion here  the  rare  cases  of  chronic  intussusception  which  generally  end 
unfavourably,  and  the  occasional  instances,  also  in  later  childhood,  of 
recovery  after  sloughing  away  of  the  imprisoned  gut. 

When  there  is  a  reasonable  suspicion  of  intussusception  chloroform 
should  be  given  or  opium  and  morphia  cautiously  administered  until 
drowsiness  be  produced.  The  bowel  should  then  be  copiously  and 
slowly  filled  with  tepid  water,  the  buttocks  being  well  elevated  by 
placing  the  child  on  an  inclined  plane,  and  the  abdomen  simultaneously 
manipulated  by  pressure  directed  towards  the  umbilicus.  Several  cases 
with  undoubted  signs  including  the  presence  of  a  palpable  abdominal 
tumour  have  been  in  this  way  successfully  reduced  at  the  Children's 
Hospital.  When  the  gut  is  gangrenous  and  very  thin  the  operation  may 
cause  perforation  and  rapidly  ensuing  death.  This  possible  accident 
however  in  no  way  contra-indicates  the  invariable  necessity  of  having 
recourse,  with  due  care,  to  this  procedure.  If  this  method  fail  air  may 
be  very  carefully  injected ;  but  after  two  unsuccessful  trials  at  most  with 
either  liquid  or  gaseous  injections  abdominal  section  should  at  once  be 
performed.  At  this  stage,  the  treatment  being  surgical,  I  would  but 
add  that  if  reduction  be  impossible  or  the  gut  in  a  very  bad  state  an 
artificial  anus  should  be  made  and  gangrenous  parts  removed.  In  cases 
where  a  tumour  can  be  felt  in  the  rectum  gentle  attempts  may  at  first 
be  made  at  reduction  by  means  of  a  sponge-tipped  probang  or  bougie, 
but  little  is  to  be  expected  from  this  procedure.  In  older  children,  as 
urged  by  Dr.  Eustace  Smith,  when  there  are  very  severe  symptoms  with 
much  prostration,  operation  by  section  is  generally  contra-indicated,  as 
not  only  giving  little  hope  of  success,  but  also  precluding  what  little 
chance  there  may  be  of  cure  by  sloughing  which  occasionally  takes 
place  even  in  cases  apparently  desperate.  I  have  known  however  but 
of  one  such  instance,  and  of  its  after  history  I  am  ignorant. 


PERITYPHLITIS  AND  TYPHLITIS.  79 

Prolapse  of  Rectum. 

This  is  a  common  affection  in  infancy  and  very  early  childhood  and 
is  generally  characterized  by  the  invagination  of  the  middle  in  the 
lower  part  of  the  rectum  and  its  protrusion  through  the  anal  ring  in 
the  form  of  a  shiny  red  swelling  which  readily  bleeds.  A  small  prolapse 
returns  by  itself  after  defalcation  while  larger  ones  require  replacement. 
Although  some  cases  are  doubtlessly  referable  to  straining  with  consti- 
pation or  to  the  lax  and  catarrhal  condition  of  the  middle  part  of  the 
rectum  in  connection  with  severe  diarrhoea  I  am  convinced  both  from 
examination  and  inquiry  in  numerous  cases  of  out-patients  that  this 
affection  very  frequently  occurs  with  no  discoverable  intestinal  disorder 
and  is  probably  due  to  a  feeble  sphincter.  It  must  be  remembered,  too, 
that  the  rectum  is  straighter  in  infancy  than  later  on,  and  that  the 
sigmoid  flexure  is  in  the  middle  line  or  sometimes  even  a  little  to  the 
right.  Straining  in  urination  may  excite  prolapse  in  time,  and  it  is 
generally  recognised  that  stone  in  the  bladder  should  be  sought  for  as  a 
possible  determining  cause  of  prolapse. 

Some  cases  get  well  with  only  a  few  replacements,  others  may  be  very 
obstinate  indeed,  but  most  recover  in  the  long  run.  The  treatment  is 
to  return  the  tumour  by  firm  pressure  with  one  or  two  fingers  on  its 
central  part  and  then  to  apply  a  thick  pad  to  the  anus,  bandaging  or 
strapping  the  buttocks  tightly  together.  Henoch  gives  a  qualified  re- 
commendation to  the  subcutaneous  injection  of  ergotin  in  the  neighbour- 
hood of  the  anus,  stating  that  it  never  does  local  harm,  often  seems  to 
do  good,  but  often  fails,  titrate  of  silver  in  strong  solution  may  be 
applied,  with  frequent  success,  to  the  surface  of  the  tumour.  In  some 
cases  surgical  treatment  directed  to  the  contraction  of  the  sphincter  ani 
is  found  necessary.  Concurrent  constipation  or  diarrhoea  should  be 
always  appropriately  treated. 


CHAPTER  VIII. 

PERITYPHLITIS    AND    TYPHLITIS. 

Clinical  and  post-mortem  observation  of  numerous  cnses  of  the  affection 
known  by  the  above  titles  has  for  many  years  convinced  me  of  the  prac- 
tical uselessness  of  endeavouring  to  make  any  distinction  between  the 
signs  and  symptoms  which  have  been  thus  nominally  differentiated.  In 
every  fatal  case  of  so-called  perityphlitis  that  I  have  examined,  and  I 
have  seen  many,  I  have  found  perforative  ulceration  of  the  vermiform 


80         DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

appendix  and  almost  always  a  faecal  calculus  which  caused  it.  I  there- 
fore follow  Dr.  Wilks'  teaching  in  this  matter,  insisting  on  the  great 
probability  of  the  disease  nearly  always  beginning  in  the  appendix, 
and  believing  that  it  is  the  varying  intensity  of  the  inflammation  that 
has  brought  the  two  terms,  typhlitis  and  perityphlitis,  into  use.  It  is 
now  very  generally  allowed  that  all  cases  thus  described,  as  well  as 
those  called  para-typhlitis,  are  really  due  to  localised  peritonitis  in  the 
neighbourhood  of  the  caecum.  There  is,  but  rarely,  apart  from  disease 
of  the  appendix  a  true  typhlitis  which  may  lead  to  perforation  and 
peritonitis,  but  I  know  nothing  of  this  affection  in  children. 

Perityphlitis  unquestionably  occurs  most  often  in  early  life,  and,  being- 
common  in  children,  deserves  notice  although  possessing  no  very  special 
clinical  characters  to  differentiate  it  from  the  adult  affection.  My  ex- 
perience is  quite  in  accord  with  that  of  many  others  that  males  of  all 
ages  suffer  much  more  often  than  females,  that  in  infants  the  affection 
is  very  rare,  and  that  in  children  generally  there  is  a  greater  proportion 
of  cases  of  short  duration  and  apparently  favourable  termination  than 
in  adults  in  whom  the  formation  of  abscess  seems  considerably  more 
frequent. 

Besides  faecal  calculi  in  the  appendix,  which  are  certainly  by  far  the 
most  common  causes  of  fatal,  and  probably  of  all,  cases  of  typhlitis  in 
children,  foreign  bodies  such  as  seeds,  fruit-stones,  &c.  have  occasionally 
been  found  in  the  same  position,  and  some  of  them  may  form  the  nucleus 
of  a  subsequently  harmful  fsecal  concretion.  In  infants  the  diameter  of 
the  colon  bears  a  much  smaller  proportion  to  that  of  the  appendix  than 
in  later  life,  and  thus  the  entrance  of  faeces  and  foreign  bodies  may  be 
favoured.  I  have,  as  above  stated,  seen  no  instance  myself  of  simple 
catarrhal  inflammation  resulting  in  ulceration,  or  of  a  primary  ulcera- 
tion of  the  caecum,  leading  to  perforation  ;  but  cases  of  this  kind  have 
been  reported,  and  it  is  possible,  considering  some  instances  of  recovery 
where  subsequently  gall-stones  or  other  concretions  or  foreign  bodies 
have  been  discharged  per  anum,  that  an  original  typhlitis  may  have 
occurred.  It  is  stated  by  some  authorities,  with  however  but  little 
support  from  cases  in  point,  that  distension  of  the  caecum  by  faecal 
matter  or  as  some  put  it,  "  constipation  "  is  by  itself  the  most  frequent 
determining  cause  of  "  typhlitis."  I  strongly  oppose  this  view  having 
found  neither  history  nor  clinical  evidence  of  chronic  constipation  in  my 
cases.  The  reported  instances  moreover  of  even  fatal  distension  of  the 
intestines  with  hardened  faeces  do  not  point  to  ulceration  as  one  of  their 
results.  Only  rarely  does  specific  ulceration  of  the  caecum  from  enteric 
fever  or  tuberculosis  lead  to  signs  of  typhlitis  and  perforation,  most  cases 
of  perforation  from  these  causes  being,  as  is  well  known,  sudden  and  not 
preceded  by  local  evidence  of  typhlitis. 


PERITYPHLITIS  AND  TYPHLITIS.  8 1 

The  symptoms  and  course  of  typhlitis  vary  widely  with  the  rapidity 

and  other  accidents  of  the  process.  The  evidence  of  local  inflammation 
without  suppuration  will  often  disappear  in  two  or  three  weeks.  If 
there  be  suppuration  the  case  may  be  of  much  longer  duration  unless 
surgically  treated,  and  the  abscess  may  burst  externally  or,  though  less 
often,  into  the  abdominal  cavity.  In  some  cases  there  is  marked  evidence 
of  peritonitis  which  may  become  general,  and  will  then  argue  certain 
perforation.  In  others,  after  apparent  recovery,  adhesions  or  chronic- 
abscesses  result  which  may  lead  to  recurrence  of  the  original  symptoms. 
Thus  on  the  one  hand  the  signs  may  be  merely  local,  such  as  pain  and 
tenderness,  fulness  or  swelling  in  the  right  iliac  region,  and  this  whether 
or  not  the  inflammatory  process  may  have  spread  from  its  original  seat 
in  the  appendix  or  elsewhere  and  have  involved,  with  or  without  per- 
foration, the  surrounding  tissues.  In  the  probably  frequent  cases  of 
perforation  of  the  vermiform  appendix  with  only  local  symptoms  and 
favourable  event  adhesions  doubtless  shut  off  the  morbid  process  from 
the  general  cavity  of  the  peritoneum,  a  result  which  is  favoured  by  the 
anatomy  of  the  region.  On  the  other  hand  the  original  ulcer  may  quickly 
proceed  to  perforation  with  scarcely  any  warning  symptoms  and  thus 
communicate  freely  with  the  peritoneum,  setting  up  at  once  the  symp- 
toms of  acute  peritonitis  or  obstruction  of  the  bowel  the  local  cause  of 
which  can  then  be  arrived  at  by  inference  alone.  It  may  indeed  be  said 
that  acute  peritonitis  coining  on  suddenly  in  a  previously  healthy  child 
beyond  infancy  is  in  a  large  majority  of  cases  due  to  perforation  from 
appendicular  ulceration.  I  have  much  evidence  in  my  case-books  to 
show  that  purulent  peritonitis  after  a  short  illness  in  children  is  mostly 
due  either  to  this  cause  or  to  external  traumatism.  Occasionally  it  is 
the  result  of  perforation  of  tubercular  ulcers  or  of  suppurating  mesenteric 
glands. 

Common  to  most  cases  that  I  have  seen  are  a  more  or  less  sudden 
origin  with  severe  pain  and  tenderness  in .  the  caecal  region  and,  sooner 
or  later,  retching  or  vomiting.  In  some  instances,  however,  there  has 
been  a  previous  history  of  the  local  symptoms  for  some  time  before 
their  severity  prevented  the  patient  from  walking.  The  temperature  is 
generally  though  not  always  raised,  and  on  examination  a  swelling  may 
usually  be  found  in  the  right  iliac  fossa  over  which  the  percussion  note 
lacks  resonance.  Marked  constipation  mostly  prevails,  but  sometimes 
there  is  even  diarrhoea  throughout.  The  right  thigh  is  often  flexed,  and 
pain  is  caused  by  attempts  at  its  extension.  In  numerous  cases  which 
end  favourably  the  symptoms  abate  after  some  days,  the  bowel  action 
returns,  and  convalescence  is  gradually  established ;  but  the  tendency  to 
recurrence  must  always  be  remembered.  It  is  impossible  in  the  cases 
which  recover  to  say  how  far  the  typhlitic  or  appendicular  inflammation 

F 


82         DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

has  progressed,  or  even  whether  perforation  has  taken  place  or  not. 
It  is  not  improbable  that  there  is  some  degree  of  localised  peritonitis  in 
every  case.  In  the  more  severe  instances  where  the  tenderness  is  very 
acute  and  the  fever  high  we  have  almost  certainly  to  deal  with  a 
localised  peritonitis.  A  small  perforation  of  the  appendix  may  doubt- 
less take  place  and  the  orifice  be  sealed  up  by  adhesions  in  cases  which 
recover,  evidence  of  which  I  have  seen  in  a  cadaver  after  death  from 
thoracic  disease.  On  the  other  hand  in  the  case  of  a  boy  of  fourteen, 
who  was  admitted  into  Westminster  Hospital  with  acute  symptoms  of 
bowel  obstruction  and  rapidly  following  signs  of  peritonitis  after  a  kick 
on  the  abdomen  at  football,  there  was  found  post-mortem  a  congenital 
and  very  narrow  constriction  of  the  small  intestine  about  5  feet  from 
the  pylorus.  The  bowel  at  this  point  had  become  doubled  on  itself  and 
fixed  by  thick  but  quite  fresh  lymph  which  was  a  part  of  acute  general 
peritonitis  set  up  by  the  perforation  of  a  small  sharp-pointed  fsecal 
calculus  found  protruding  from  the  wall  of  the  vermiform  appendix. 
The  perforation  in  this  case  was  in  all  probability  immediately  caused 
by  the  kick.  When  the  perforation  occurs  posteriorly,  and  there  is  thus 
a  probability  of  the  peritonitis  being  limited,  the  symptoms  may  be 
chronic  and  an  abscess  may  form  after  a  considerable  time.  Here  it  is 
important,  as  in  all  cases  of  insidious  origin,  to  exclude  the  presence  of 
hip-disease  by  the  ordinary  tests.  There  may  be  nothing  at  this  stage 
to  indicate  involvement  of  the  bowel,  and  there  may  or  may  not  be  the 
usual  constitutional  symptoms,  more  or  less  severe,  of  a  collection  of 
pus.  Such  cases  are  as  a  rule  of  very  bad  prognosis,  although  they  may 
endure  for  long.  In  those  instances,  then,  where  the  first  symptoms 
observed  are  local  pain  and  tenderness  with  constipation  and  retching 
or  vomiting  and  the  diagnosis  leading  to  appropriate  treatment  is  made 
early,  the  prognosis  is  as  a  rule  good,  with  the  exception  of  the  com- 
paratively few  which  in  spite  of  all  care  go  on  to  abscess.  This  class, 
as  has  already  been  observed,  may  possibly  include  many  of  even  perfora- 
tion of  the  appendix.  When,  however,  the  early  signs  are  those  of  acute 
peritonitis,  often  accompanied  by  urgent  symptoms  of  obstruction,  the 
prognosis  is  very  grave.  There  does  not  seem  to  be  any  further  ground 
for  distinction  between  the  cases  which  die  and  those  which  recover. 

As  regards  treatment,  absolute  rest  in  bed  with  the  limbs  supported 
in  the  most  comfortable  position  must  be  enforced  in  all  cases  suspected 
or  diagnosed  as  typhlitis.  The  event  in  many  cases,  especially  in  those 
where  only  local  signs  exist,  depends  largely  on  proper  treatment,  no 
small  part  of  which  is  the  avoidance  of  purgation  which  has  been  so 
often  resorted  to,  with  or  without  medical  advice,  in  cases  admitted  to 
hospital.  Opium  should  always  be  freely  given,  not  only  for  allaying 
pain  and  giving  rest  to  the  bowels  but  also  for  its  probably  antiphlogistic 


PERITONITIS  AND  ABDOMINAL  TUBERCLR  8  J 

effect.  The  diet  should  be  liquid,  and  consist  partly  of  milk  and  partly 
of  meat-juices.  Hot  poultices  to  the  abdomen  give  much  relief,  but 
they  should  be  very  light  and  therefore  frequently  renewed.  If  there 
be  much  pain  and  fulness  leeching  over  the  affected  part  is  often  of 
great  service.  When  pus  is  indicated  a  careful  examination  should  be 
made  by  aspiration,  and  indeed  in  all  cases  which  are  becoming  rapidly 
worse  an  exploratory  operation  is  advisable,  even  when  no  fluctuation 
can  be  demonstrated.  When  pus  has  been  found  it  should  be  removed 
by  incision.  In  all  cases  the  more  definite  the  swelling  the  less  delay 
should  there  be  in  exploring  for  pus. 

Careful  dieting  and  rest  should  always  be  insisted  on  for  a  few  weeks 
after  recovery,  for  relapses  may  probably  thus  be  prevented.  If  con- 
stipation persist,  as  it  but  rarely  does,  after  all  other  symptoms  have 
disappeared  the  bowels  should  be  acted  on  by  enemata  or  gentle  pur- 
gatives.    Otherwise  no  medicine  is  required. 

The  medico-chirurgical  question  of  excision  of  the  vermiform  appendix 
for  the  purpose  of  preventing  that  return  of  the  affection  which  clinical 
experience  gives  us  cause  to  dread  may  be  said  to  be  still  sub  judice, 
but  in  properly  selected  cases  the  operation  seems  to  be  one  of  good 
promise.  I  do  not  think  that  relapsing  typhlitis  is  common  in  children, 
but  when  it  does  occur  and  there  remains  any  swelling  in  the  iliac  region 
to  make  diagnostic  assurance  doubly  sure,  surgical  interference,  and  pro- 
bably removal  of  the  appendix,  is  indicated.  Mr.  Treves  reports  a  case 
in  a  man  with  thrice-recurrent  appendicular  inflammation  where  the 
operation  was  successful  and  was  undertaken  at  a  time  when  there  wa& 
neither  sign  nor  symptom  of  active  disease. 


CHAPTER  IX. 

PERITONITIS    AND    ABDOMINAL   TUBERCLE. 

Acute  Peritonitis. 

As  in  the  adult,  acute  peritonitis  may  be  the  essential  affection,  and  is 
then  generally  due  to  perforation  through  intestine  or  traumatism  ;  or 
it  may  be  secondary  to  more  generalised  disease.  In  the  latter  class  of 
cases  the  symptoms  of  its  onset  may  be  but  slightly  marked  or  altogether 
absent.  Abdominal  pain  and  tenderness,  fever  with  or  without  rigors, 
and  vomiting  are  the  main  initial  symptoms  ;  the  belly  soon  becomes  dis- 
tended and  almost  motionless,  the  face  pinched  and  pale,  the  nostrils 


84        DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

distended,  and  there  may  be  violent  paroxysms  of  intestinal  colic. 
There  may  or  may  not  be  evidence  of  ascites.  In  the  majority  of  cases 
the  distension  is  chiefly  gaseous.  Although  constipation  is  the  rule 
diarrhoea  is  sometimes  present  in  the  early  stage  or  even  throughout, 
and  in  some  cases  there  is  but  little  or  no  evident  rise  of  temperature, 
the  condition  of  nervous  collapse  so  frequently  incident  on  abdominal 
injury  probably  preventing  this  symptom. 

The  picture  of  acute  peritonitis  in  children  can  best  be  drawn  from 
the  cases  which  result  from  perforative  disease  of  the  appendix  as  pre- 
viously described ;  for  the  rest,  it  is  not  common  except  in  its  secondary 
and  often  less  marked  forms.  Generalised  acute  peritonitis  is  almost 
always  fatal.  The  cases  of  purulent  peritonitis  which  recover  after  dis- 
charge through  the  umbilicus  or  other  parts  of  the  abdominal  wall,  or 
after  surgical  incision,  are  probably  more  or  less  localized  peritoneal 
abscesses.  The  best  examples  of  this  are  supplied  by  some  typhlitic 
events,  and  the  results  of  falls,  blows,  or  kicks  on  the  abdomen.  Of  the 
latter  class  of  cases  Henoch  gives  several  instances.  The  following  case 
of  my  own  is  to  the  point. 

A  girl  of  six  years  old,  previously  healthy,  complained  of  abdominal 
pain  and  vomited  frequently  a  few  days  after  falling  on  her  belly  over  a 
ladder.  The  pain  was  continuous  until  admission  to  hospital  a  fortnight 
later.  She  was  then  very  restless,  and  abdominal  dulness  and  fluctua- 
tion were  marked  although  there  was  resonance  in  the  flanks.  Two  days 
after  admission  friction  sounds  were  heard  at  both  pulmonary  bases,  and 
especially  at  the  right  where  there  was  some  loss  of  resonance.  After  a 
fortnight,  the  abdominal  distension  being  somewhat  greater,  I  ordered 
tapping  at  a  point  near  the  umbilicus,  and  2  J  pints  of  ordinary  pus  was 
withdrawn.  General  improvement  followed,  and  the  temperature  rarely 
rose  above  normal ;  but  gradually  there  appeared  signs  of  increased  fluid, 
and  in  the  course  of  three  weeks  Mr.  Parker  at  my  request  made  an 
incision  in  the  middle  line  between  the  umbilicus  and  pubes  and  let  out  a 
pint  and  a  half  of  pus.  The  intestines  were  found  to  be  matted  together 
and  the  liver,  spleen  and  transverse  colon  were  distinctly  felt.  The 
peritoneum  was  washed  out  antiseptically,  a  drainage  tube  inserted,  and 
the  wound  nearly  closed.  After  a  discharge  for  a  few  days  the  patient 
quickly  recovered  and  was  quite  well  and  about  in  a  fortnight,  the 
physical  signs  of  the  probably  secondary  pleurisy  having  disappeared. 

Apart  from  typhlitis  and  external  traumatism  acute  peritonitis  in 
children  may  result  from  perforation  of  intestinal  ulcers,  as  in  enteric 
fever,  and,  but  very  rarely,  from  that  of  gastric  ulcers  or  the  suppura- 
tion of  abdominal  glands.  It  may  also  arise  suddenly  in  connection 
Avith  general  tuberculosis  either  as  an  early  or  late  symptom  of  the  dis- 
ease.    In  a  secondary  form  it  may  occasionally  occur  as  extension  from 


PERITONITIS  AND  ABDOMINAL  TUBERCLE.  85 

purulent  pleurisy,  or  from  the  breaking  of  an  empyema  through  the 
diaphragm.  Certain  cases  must  be  put  down  to  more  general  causes, 
including  septicaemia.  Such  are  those  which  are  seen  in  the  foetus  or 
the  newly-born,  with  or  without  jaundice,  some  of  which  are  perhaps 
syphilitic  ;  in  the  advanced  stage  of  scarlatinal  nephritis  ;  and  in 
occasional  grouped  or  isolated  instances  reported  by  various  observers 
where  a  purulent  peritonitis  seems  to  be  the  main  characteristic  of  a 
generally  fatal  "  blood-poisoning."  Of  such  I  have  seen  a  few  instances 
both  in  children  and  adults.  I  have  no  hesitation  however  in  expressing 
the  greatest  doubt  as  to  the  existence  of  "idiopathic"  peritonitis,  or  a 
peritonitis  due  to  "  chill  "  alone  ;  and  I  can  say  nothing  about  rheumatic 
peritonitis,  at  least  in  children.  A  careful  search  and  due  inquiry  or 
post-mortem  dissection  will  as  a  rule  negative  this  unsatisfactory  diagnosis. 
Although  I  once  saw  a  fatal  case  in  a  weakly  child  about  four  years 
old,  where  it  was  said  that  careful  examination  post-mortem  failed  to 
indicate  the  cause  of  the  peritonitis,  I  would  refer  this  in  the  light  of 
general  experience  rather  to  some  undiscovered  lesion  or  to  the  possible 
cause  of  external  traumatism  than  to  a  still  more  hypothetical  idiopathy. 

The  prognosis  of  acute  peritonitis  is  least  unfavourable  in  cases  where 
there  is  reason  to  believe  it  is  more  or  less  localised,  and  in  those,  pro- 
bably of  the  same  order,  which  are  due  to  external  traumatism.  When 
this  affection  is  due  to  a  lesion  which  permits  the  escape  of  the  contents 
of  hollow  organs  into  the  cavity,  or  is  secondary  to  other  diseases,  it  is 
mostly  of  fatal  augury.  It  must  be  remembered  that  secondary  peritonitis, 
although  generally  causing  distension  of  the  abdomen,  is  not  unfre- 
quently,  especially  in  exhausted  patients,  unmarked  by  clear  symptoms 
and  discovered  only  post-mortem. 

As  to  diagnosis,  the  not  infrequent  mistake  of  taking  peritonitis  for 
mechanical  bowel  obstruction  with  the  occasional  maltreatment  directed 
towards  the  latter  affection  is  deserving  of  notice.  The  careful  thera- 
peutist will  refrain  from  even  accidentally  clearing  up  the  diagnosis 
between  the  constipation  of  peritonitis  and  that  of  obstruction  by  means 
of  a  purge  or  enema,  and  thus  this  difficulty  at  least  must  remain.  Pascal 
vomiting  too,  may  take  place  in  acute  peritonitis,  as  I  have  seen  in  one 
unquestionable  case  with  a  post-mortem  ;  and  it  must  be  remembered  that 
both  abdominal  distension  and  tenderness  without  melaena  may  very  occa- 
sionally occur  even  at  the  outset  of  a  case  of  intussusception.  Pleurisy, 
mainly  localised  at  the  diaphragm,  may  be  mistaken  for  peritonitis,  and 
there  may  be  no  thoracic  signs  in  some  cases,  at  least  for  some  days,  to 
establish  the  diagnosis.  Possible  mistakes,  however,  in  diagnosis  are  not 
of  much  practical  importance,  provided  we  always  treat  even  a  suspected 
case  of  peritonitis  by  avoidance  of  purgatives,  absolute  rest,  a  scanty 
fluid  diet,  and  sufficient  opium  to  produce  a  slight  degree  of  narcotism. 


86         DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

"With  ordinary  caution  we  shall  then  never  kill,  though  we  may,  if  our 
provisional  diagnosis  be  correct,  but  rarely  cure.  Attempts  to  relieve 
pain  should  be  further  made  by  the  application  of  heat,  without  undue 
pressure,  to  the  abdomen,  and  for  this  purpose  a  bran  poultice  is  better 
than  a  linseed  one.     Leeches  too  are  often  of  service. 


Chronic  Peritonitis  and  Abdominal  Tubercle. 

It  is  but  very  rarely  that  chronic  peritonitis  other  than  tubercular  comes 
under  our  observation  in  children.  Doubtless  chronic  peritonitis  evi- 
denced only  or  mainly  by  ascites  may  exist,  as  is  shown  by  an  important 
case  of  traumatic  origin  reported  by  Henoch  ;  and  it  is  seen  from  time  to 
time  as  the  result  of  malignant  growths,  especially  of  sarcomatous  tumour, 
arising  generally  in  the  post-peritoneal  glands  and  sometimes,  but  rarely, 
in  the  peritoneum  itself.  The  nature  of  a  considerable  number  of  cases 
Avhich  recover,  especially  in  children,  will  perhaps  always  remain  in  some 
doubt,  but  the  ample  post-mortem  evidence  we  now  have  of  the  obso- 
lescence of  both  peritoneal  and  other  tubercle  favours,  on  the  whole,  the 
diagnosis  of  tubercular  peritonitis  in  most  recoveries  where  traumatism 
can  be  in  all  probability  excluded. 

Post-mortem  examination  proves  that,  while  in  a  very  large  majority 
of  cases  peritoneal  tubercle  is  coincident  with  tubercle  elsewhere  and 
notably  in  the  mesenteric  and  bronchial  glands  and  in  the  lungs,  yet 
it  may  occur  alone.  I  have  seen  one  case  where  the  abdominal  organs 
were  adherent  to  the  walls,  the  peritoneal  cavity  being  obliterated  and 
the  surface  almost  entirely  invaded  with  nodules  of  yellow  tubercle, 
while  there  was  absolutely  no  other  lesion  than  necrosis  of  the  upper 
jaw.  The  chief  symptoms  of  the  disease  are  wasting,  vomiting,  abdo- 
minal pain  and  enlargement,  diarrhoea,  and  some  degree  of  fever,  but 
these  may  occur  in  different  combinations,  and  some  may  be  absent  alto- 
gether. Most  cases  begin  insidiously  with  some  pain,  sickness,  diarrhoea 
and  fever,  but  the  after-course  varies  much.  In  those  which  go  on  to 
enlargement  from  effusion  of  fluid  all  other  symptoms  besides  a  certain 
degree  of  wasting  often  cease ;  the  enlargement  may  sometimes  be  great, 
but  in  most  cases  the  abdominal  walls  do  not  become  very  tense.  In  these 
cases  the  diagnosis  from  ascites  of  hepatic  origin  depends  chiefly  upon 
pathological  experience  which  tells  us  that  chronic  peritoneal  effusion 
in  children  is  generally  of  tubercular  origin.  Not  infrequently  such 
cases  recover,  at  least  apparently,  with  good  nourishment  and  hygienic 
surroundings,  with  or  without  repeated  tapping.  After  drawing  off 
the  fluid  we  may  often  detect  indurated  masses  in  the  region  of  the 
umbilicus  or  other  parts.  Other  cases  of  peritoneal  tubercle  are  charac- 
terized by  absence  of   fluid,   and  the  abdomen   may  be    but   slightly 


PERITONITIS  AND  ABDOMINAL  TUBERCLE.  87 

enlarged  or  even  retracted.  Hard  masses  of  different  size,  shape  and 
position  may  be  felt  through  the  walls,  owing  to  a  thickening  of  the 
omentum  and  its  adherence  to  the  transverse  colon,  to  sacculated  exu- 
dations or  matting  together  of  the  intestines.  There  may  be  little 
or  no  pain  or  tenderness.  Many  cases  are  complicated  with  the  signs 
and  symptoms  of  intestinal  or  pulmonary  tubercle,  such  as  continuous 
diarrhoea,  cough,  fever  and  rapid  wasting,  and  not  a  few  which  have 
run  a  very  chronic  course  may  suddenly  sicken  and  rapidly  die  Avith 
evidence  of  tubercle  of  the  pia  mater.  I  have  seen  several  times,  as 
in  adults,  an  inflammatory  thickening  with  a  red  blush  on  the  skin  hi 
the  region  of  the  umbilicus  as  described  by  Fagge.  In  two  cases  there 
was  a  discharge  of  sero-pus  'from  the  umbilicus.  Often,  however,  this 
induration  and  redness  after  a  while  disappear  altogether. 

It  has  been  well  remarked  by  Dr.  Osier  that  there  is  the  closest 
analogy  between  tubercle  of  the  peritoneum  and  of  the  lung,  for  we  see 
in  both  the  fresh  miliary  eruption,  the  caseous  ulcerating  masses,  and 
the  chronic  fibroid  and  often  pigmented  nodules.  The  varying  clinical 
course  of  this  disease,  from  the  acutest  to  the  almost  wholly  latent  form, 
is  thus  explained.  Pleurisy,  often  of  the  dry  form,  is  very  frequently 
associated  with  this  affection  and  is  not  always  accompanied  by  actual 
tubercle  of  the  pleura.  Ascites,  as  we  have  seen,  is  not  as  a  rule  exten- 
sive, though  most  often  present  in  some  degree,  but  tympanites  from 
gaseous  distension  of  the  bowels,  sometimes  extreme,  is  very  common. 
In  several  of  my  cases,  including  those  which  were  steadily  becoming 
worse,  I  have  noted  the  continuous  absence  of  pyrexia  and  sometimes 
even  a  subnormal  temperature  as  described  by  others  and  dwelt  on  by 
Dr.  Osier.  The  most  chronic  cases  are  those  where  the  tubercle  is 
limited  to  the  peritoneum  or  slightly  involves  also  the  mucosa  of  the 
intestines  and  mesenteric  glands.  Diarrhoea  of  persistent  character 
generally  indicates  tubercular  ulceration  of  the  intestines.  In  the 
majority  of  fatal  cases  there  is  found  fatty  enlargement  of  the  liver. 

The  diagnosis  of  tubercular  peritonitis  presents  far  less  difficulty  in 
childhood  than  in  adidt  life  when  the  confusion  of  it  with  ovarian  dis- 
ease and  also  with  malignant  growths  is  frequent  and  sometimes  unavoid- 
able. In  every  case  careful  search  must  be  made  for  the  evidence  of 
tubercle  elsewhere,  and  due  attention  should  be  given  to  the  previous 
and  family  history  of  the  patient. 

That  tubercle  of  the  peritoneum  may  spontaneously  become  inactive  is 
now  amply  proved  by  clinical  and  anatomical  research,  and,  although  the 
cases  in  which  recovery  takes  place  are  mainly  those  of  mild  onset  and 
inextensive  signs,  even  large  effusions  of  undoubtedly  tubercular  nature 
have  been  known  to  disappear.  I  have  no  doubt  of  this  fact  from  my 
own  experience  although  I  am  unable  to  give  a  crucial  instance  with 


88         DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

anatomical  proof.  We  have  therefore  every  encouragement  to  follow 
any  line  of  treatment  which  experience  may  suggest  to  assist  the  arrest 
of  the  tubercular  process.  Cod-liver  oil,  iron  and  arsenic  may  be  all 
useful  either  separately  or  combined.  Possibly  the  hypophosphites, 
which  are  always  harmless,  may  do  good.  I  have  tried  them  many  times 
in  deference  to  the  authority  of  good  observers  but  have  not  much  reason 
to  speak  in  their  favour.  Above  all  things  fresh  air  with  a  nourishing 
diet  should  be  strictly  insisted  on.  In  those  not  very  frequent  cases 
where  there  is  distinct  liquid  effusion  causing  distension  I  believe  tapping 
to  be  decidedly  useful.  I  have  not  found  any  good  to  result  from  painting 
or  anointing  the  abdomen  with  any  counter-irritant  or  absorbent. 

Of  "  laj)arotomy  "  I  have  had  no  experience  in  my  own  cases,  and  from 
the  general  clinical  course  of  this  disease  in  early  life  I  am  of  opinion 
that  treatment  by  this  method,  curative  though  it  may  possibly  have 
been  in  some  adult  cases,  will  be  but  seldom  applicable  to  children. 
According  to  the  advocates  of  this  operation  those  cases  which  begin 
suddenly  with  some  fever  and  considerable  ascites,  without  evidence  of 
tubercle  elsewhere,  are  the  best  subjects  for  this  treatment,  but  I  believe 
that  this  class  of  cases,  rare  altogether,  is  very  rare  in  children.  On  the 
whole  it  would  seem  advisable  in  peritonitis  deemed  to  be  tubercular, 
apparently  uncomplicated  Avith  tubercle  elsewhere,  and  withal  rapidly 
progressing  with  acute  or  sub-acute  symptoms,  that  the  abdomen  should 
be  opened  and  the  cavity  drained  according  to  the  approved  methods  of 
modern  surgery.  But  in  all  cases  of  insidious  onset  and  slow  progress, 
whatever  be  the  physical  signs,  the  operative  hand  should  be  stayed  for 
a  while  by  the  certain  knowledge  that  the  disease  is  sometimes  naturally 
cured. 

Chronic  peritoneal  mischief  with  ascites,  due  to  sarcomatous  disease  of 
the  abdominal  glands,  may  generally  be  diagnosed  or  suspected  by  the 
presence  of  rapidly  growing  tumours  which  can  usually  be  felt ;  but  in 
those  rare  cases  where  the  peritoneum  itself  is  the  main  seat  of  the  sar- 
comatous process  nothing  perchance  may  be  established  on  examination 
besides  ascites. 


CHAPTER  X. 

ON    ASCITES,  JAUNDICE   AND    DISEASES    OF    THE    LIVER. 

Ascites. 

Peritoneal  effusion  in  children  whether  it  be  of  inflammatory  origin  or 
not  requires  but  little  special  consideration.  As  in  adults,  so,  although 
rarely,  in  quite  young  children  it  may  be  a  part  of  the  general  circulatory 


ASCITES,  JAUNDICE  AND  DISEASES  OF  LIVER.  89 

.stasis  from  heart  disease,  especially  when  there  is  tricuspid  regurgi- 
tation, and  it  may  also  be  seen  in  chronic  renal  disease.  Abdominal 
tumours,  mostly  sarcomatous,  beginning  in  the  omentum  or  in  the  retro- 
peritoneal glands  and  connective  tissue,  are  the  cause  of  some  cases  by 
obstructing  the  peritoneal  circulation,  and  more  or  less  ascites  from  acute 
or  chronic  peritonitis,  mainly  of  the  tubercular  form,  is  of  frequent  occur- 
rence, though  in  the  majority  of  cases  not  excessive.  Non-tubercular 
peritonitis,  though  rare  as  a  cause  of  chronic  ascites,  must  also  be  re- 
membered. One  such  case  at  least  I  have  seen  in  a  child  in  whom  the 
effusion  appeared  soon  after  a  fall  across  a  gate  and  nodular  masses 
were  felt  in  the  abdomen  after  withdrawal  of  the  fluid.  Recovery  with 
disappearance  of  all  abnormal  signs  was  ultimately  complete. 

Ascites  arising  from  cirrhosis  of  liver,  pylephlebitis,  inflammation  of 
the  hepatic  veins  secondary  to  perihepatitis  (Hillier),  syphilitic  disease 
either  of  the  liver  itself  or  causing  obstruction  of  the  trunk-vein  in  the 
portal  fissure,  or  from  glandular  enlargement,  tubercular  or  otherwise,  in 
the  fissure,  requires  no  detailed  description.  In  any  case  of  ascites, 
otherwise  unexplained,  syphilis  should  always  be  thought  of  as  a 
probable  cause. 

In  children  beyond  infancy  it  is  not  very  rare  to  meet  with  ascites 
even  of  great  degree  and  long  duration  which  is  clinically  referable 
neither  to  peritonitis  nor  to  any  discoverable  cause  other  than,  in 
some  instances,  hepatic  enlargement  which  may  be  very  patent  to  exa- 
mination especially  when  the  fluid  has  been  removed  by  absorption 
or  by  tapping.  I  have  seen  three  such  cases  which  have  begun  gradu- 
ally in  children  of  previously  apparent  good  health  and  have  ultimately 
recovered  with  or  without  one  or  more  tappings,  the  only  permanent 
sign  being  an  enlarged  liver.  Hillier  refers  to  cases  apparently  of  this 
kind,  and  suggests  that  they  may  be  due  to  thrombosis  in  veins,  or 
to  pressure  on  them  by  external  plastic  exudation,  enlarged  glands  or 
tumour.  In  one  case  of  mine  in  a  girl  aged  fourteen  the  abdomen  was 
tapped  four  times  at  considerable  intervals,  120  ounces  being  removed  at 
the  first  operation  and  1 2  at  the  last.  Two  years  afterwards  I  saw  her 
in  apparently  perfect  health  but  with  a  much  enlarged  liver.  On  first 
admission  there  was  a  systolic  murmur  at  the  cardiac  apex  which  soon 
disappeared.  The  urine  was  scanty  throughout  the  course  of  the  case 
which  was  under  treatment  for  nearly  a  year,  but  there  was  never  any 
albuminuria  or  abdominal  pain.  Cases  of  this  kind  are  perhaps  best 
referred  provisionally,  in  our  ignorance  of  their  nature,  to  some  chronic 
form  of  interstitial  hepatitis. 

In  a  case  of  a  boy,  aged  9^  when  first  seen,  there  were  two  attacks  of 
ascites  with  scanty  urine  lasting  about  three  months  each  with  an  in- 
terval of  nine  months.     During  the  first  attack  there  were  auscultatory 


90         DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

signs  of  some  tederua  of  the  lungs,  with  occasional  slight  albuminuria, 
but  no  other  discoverable  dropsy.  There  was  no  albuminuria  or  other 
symptom  in  the  second  attack  from  which  he  recovered  with  apparent 
completeness.  The  liver  was  much  enlarged  throughout.  In  this  case, 
however,  there  might  be  some  suspicion  of  other  than  hepatic  origin. 

It  is  often,  of  course,  very  difficult  to  eliminate  peritonitis  as  a  cause  of 
some  obscure  cases  of  ascites.  The  following  case  would  appear  from 
the  history  to  be  of  this  nature.  A  girl  aged  8,  previously  quite  well, 
had  severe  pain  followed  by  rapid  enlargement  of  the  abdomen.  On 
admission  soon  afterwards  there  were  found  extensive  ascites  and  double 
pleural  effusion  with  friction  sounds.  During  her  stay  of  two  months 
in  hospital,  after  which  she  left  perfectly  well  and  Avith  no  abnormal 
physical  signs,  there  was  at  first  some  intermittent  pyrexia. 

As  a  general  rule  a  peritonitic  cause  may  be  inferred  when  there  is 
or  has  been  abdominal  pain  and  tenderness,  and  especially  when  these 
symptoms  follow  on  a  febrile  attack,  with  headache,  vomiting,  diarrhoea 
or  wasting.  If  nodules  can  be  felt  in  the  abdomen  the  case  is  most 
probably,  though  not  certainly,  tubercular. 

A  large  peritoneal  effusion  may  perhaps  cause  secondary  oedema  of 
the  feet  and  legs  by  pressure  on  the  abdominal  veins,  and  sometimes 
greatly  contracts  the  thoracic  cavity  by  raising  the  diaphragm  and  thus 
compressing  the  lungs  with  the  result  of  producing  much  dyspnoea. 
The  symmetrical  loss  of  resonance  often  noted  at  both  pulmonary  bases 
is  probably  due  to  collapse  of  lung  and  must  not  be  too  lightly  attributed 
to  pleural  effusion.  It  is  unnecessary,  owing  to  their  rarity,  to  do  more 
than  barely  mention  ovarian  cysts  and  hydronephrosis  as  possible  sources 
of  error  in  the  diagnosis  of  ascites,  even  in  young  children.  In  the 
treatment  of  ascites  we  must  take  all  pains  to  discover  the  cause  and 
thereby  direct  our  hygienic  and  medicinal  remedies.  It  is  well  in  all 
peritoneal  effusions  of  such  extent  as  to  cause  much  inconvenience,  and 
especially  dyspnoea,  to  remove  the  fluid  at  once  by  tapping.  In  propor- 
tion as  an  ascites  is  symptomatically  but  little  complicated  and  not  pro- 
bably referable  to  kidney-  or  heart-disease  all  methods,  according  to  my 
experience,  fail  which  are  directed  towards  the  promotion  of  diuresis, 
diaphoresis  or  intestinal  flux.  I  believe  that  hot-air  baths  are  here 
practically  ineffectual,  as  are  all  the  medicinal  remedies  in  popular  use. 
My  case-books  of  past  years  contain  many  records  of  failure  to  reduce 
ascites  by  copaiba-resin,  squills,  digitalis,  the  alkaline  diuretics  and 
pilocarpin.  Tapping  therefore  should  be  performed  whenever  the  symp- 
tomatic distress  is  great,  and  should  be  repeated,  but  at  intervals  of 
some  weeks,  when  without  any  distress  the  fluid  is  demonstrably  re- 
increasing.  I  believe  that  repeated  tapping  makes  for  cure  in  some 
cases.     The  diet  should  always  be  nutritious,  unless  contra-indicated  by 


ASCITES,  JAUNDICE  AND  DISEASES  OF  LIVER.  Q1 

other  symptoms,  and  m>t  lucking  in  fluid.  Iron  and  other  tonics  with 
plenty  of  air  and  light  are  often  of  great  importance.  In  such  of  my 
cases  as  ultimately  recovered  or  seemed  to  recover  much  greater  im- 
provement was  made  at  convalescent  homes  without  active  treatment 
than  at  any  period  of  hospital  residence,  except  so  far  as  immediate 
relief  by  tapping  was  concerned  in  those  patients  who  required  it. 

Jaundice  and  Diseases  of  the  Liver. 

Infants  both  at  birth,  and  soon  afterwards  may  be  the  subjects  of 
jaundice  which  is  either  transient,  with  no  other  symptoms,  and  of  no 
serious  import,  or  connected  with  bad  nutrition  with  or  without  petechial 
haemorrhages  in  the  skin.  Jaundice  is  also  caused  by  congenital  absence 
of  the  bile-ducts  with  sometimes  no  trace  of  a  gall-bladder,  by  syphilitic 
disease  affecting  the  portal  fissure,  or  by  a  septic  condition  arising  from 
umbilical  phlebitis.  The  lirst-mentioned  form  known  generally  as  icterus 
neonatorum,  which  is  seen  mostly,  though  not  always,  in  weakly  or  pre- 
maturely born  babies  or  in  cases  of  delayed  birth  with,  impeded  respi- 
ration, is  due  to  true  bile-staining,  and,  although  its  origin  is  doubtful, 
probably  arises  from  hepatic  causes  connected  with  altered  circulation 
and  pressure  on  the  bile-ducts  in  the  liver.  The  conjunctivae  are  stained 
as  well  as  the  skin  and  sometimes  bile-pigment  in  small  quantities  is 
found  in  the  urine.  This  condition,  unaccompanied  by  any  bad  symp- 
toms, generally  passes  off  within  a  week  or  at  most  a  fortnight  from  birth. 
There  may  or  may  not  be  varying  degrees  of  staining  of  the  urine  or  loss 
of  faecal  colour.  These  cases  are  to  be  distinguished  from  a  yellowish 
discolouration  of  the  skin,  without  any  conjunctival  staining  or  other 
signs  of  jaundice,  which  sometimes  supervenes  on  the  great  cutaneous 
congestion  often  seen  at  birth. 

The  next  form,  which  is  seen  sometimes  very  soon  after  birth  in  con- 
nection with  wasting,  stomatitis,  diarrhoea  and  vomiting,  or  occasionally, 
as  mentioned  by  Henoch  and  as  in  a  case  seen  by  myself,  with  small 
cutaneous  haemorrhages,  is  probably  due  to  catarrh  of  the  bile-ducts. 
Although  from  their  general  conditions  these  cases  are  grave  they  may 
recover  completely. 

Jaundice  from  retention  of  bile  owing  to  congenital  absence  of  the  ducts 
is  always  fatal.  It  may  not  appear  until  a  few  weeks  after  birth,  and 
the  child  may  live,  without  much  wasting  at  first,  for  several  months. 
Most  however  die  much  sooner.  The  liver  in  these  cases  is  sometimes 
enlarged  early,  but  in  those  that  die  after  the  longer  course  of  the  disease 
is  usually  found  shrunken  with  destruction  of  the  cells  and  is  dark  olive 
or  black  in  hue.  In  one  case  of  the  kind  where  the  jaundice  was  seen  at 
birth  and  the  child  lived  three  weeks  the  liver  was  found  by  Dr.  Hebb 


92        DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

to  be  small  and  black  and  consisted  practically  of  fibrous  tissue  in  the 
meshes  of  which  were  granular  pigmented  and  much  degenerated  cells. 
There  was  no  trace  of  the  bile-ducts  and  only  a  fibrous  cord  in  place 
of  the  gall-bladder.  In  some  cases  of  congenital  absence  of  the  ducts 
umbilical  haemorrhage  is  observed  before  death. 

Syphilitic  disease  of  the  liver,  involving  or  not  the  gall-bladder  and 
large  ducts,  is  a  recognized  cause  of  jaundice  and  is  to  be  diagnosed  by  a 
large,  hard  and  often  uneven  liver  with  other  signs  of  syphilis.  This 
form  may  be  congenital  and  is  always  fatal.  Septic  jaundice  connected 
with  umbilical  phlebitis  is  accompanied  by  fever,  a  sanguineo-purulent 
discharge  from  the  navel  and  often  by  petechial  eruption  and  vomiting. 
Convulsions  are  apt  to  precede  death. 

In  the  diagnosis  and  prognosis  of  infantile  jaundice  we  are  guided  by 
increase  of  symptoms,  by  enlargement  of  the  liver,  by  the  concomitant 
signs  of  other  disease  and  by  the  existence  of  wasting  and  general 
discomfort  to  form  the  graver  opinion  of  hepatic  disease  or  congenital 
malformation  as  its  cause,  while  good  health  with  no  ingravescence  of 
symptoms  will  usually  justify  a  favourable  forecast.  It  is  a  sign  rather 
of  serious  disease  than  of  the  harmless  "  icterus  neonatorum  "  when  the 
symptoms  do  not  set  in  till  some  time  after  birth. 

Icterus  neonatorum  per  se  requires  no  treatment.  Cases  accompanied 
by  disturbance  of  the  alimentary  canal  or  wasting  must  be  duly  dieted, 
and,  for  the  rest,  all  possible  causal  indications  for  therapeusis  must  be 
followed.  Constipation  should  be  relieved  by  drugs  in  all  cases ;  and 
for  preference,  but  without  any  strong  conviction,  I  always  try  for  a 
while  mercurial  purgatives. 

In  children  beyond  infancy  jaundice,  though  not  common,  may  occur 
from  almost  all  the  causes  which  obtain  in  adult  life.  My  notes  in- 
clude a  few  cases  referable  to  gall-stones,  syphilitic  gummata  of  the 
liver,  or  chronic  enlargement  of  probably  cirrhotic  character  known  as 
hypertrophic  cirrhosis ;  two  cases  connected  with  acute  yellow  atrophy 
of  the  liver,  and  some  due  in  all  probability  either  to  temporary  hepatic 
congestion  or  to  so-called  catarrhal  obstruction  of  the  common  bile-duct. 
I  do  not  think,  however,  that  the  harmless  and  transient  obstructive 
jaundice  so  common  in  adults  and  referable  to  one  or  other  of  the  last 
named  causes  is  of  very  frequent  occurrence  in  children,  and  although 
jaundice  due  to  gall-stones  or  to  masses  of  inspissated  bile  in  the  ducts 
is  said  to  be  rarely  demonstrated  I  have  seen  several  cases  which  were 
symptomatically  indicative  of  this  affection,  the  existence  of  a  calculus 
being  proved  in  one. 

Two  cases  of  sisters  aged  4^  and  2\  were  of  doubtful  diagnosis.  They 
both  simultaneously  had  typically  complete  obstructive  jaundice  of  a 
week's  duration  with  severe  paroxysmal  attacks  of  pain  lasting  for  three 


ASCITES,  JAUNDICE  AND  DISEASES  OF  LIVER.  93 

or  four  days.  In  the  case  of  the  eldest  the  attack  began  with  acute  pain 
and  vomiting  as  well.  Both  children  were  perfectly  healthy  and  their 
history  practically  excluded  any  probable  dietetic  cause.  Painting  was 
going  on  in  the  house  when  the  illness  began,  but  recovery  was  rapid 
and  complete  in  unchanged  conditions. 

Acute  yellow  atrophy  as  a  cause  of  jaundice,  known  also  by  the 
clinical  name  of  "  malignant  jaundice,"  is  said  to  be  very  rare  in  child- 
hood, but,  as  the  jaundice  may  precede  all  other  symptoms,  I  quote  as  a 
warning  the  following  case  which,  until  alarming  nervous  symptoms  set 
in  a  day  or  two  before  I  saw  it  a  second  time,  completely  misled  me  into 
giving  a  good  prognosis.  A  girl  of  six  years  old  was  brought  to  me  for 
jaundice  of  about  a  week's  duration  with  light- coloured  faeces  and  dark 
urine.  Her  previous  history  was  good,  and  beyond  one  or  two  rather 
severe  attacks  of  abdominal  pain  and  a  slight  occasional  irritability  there 
had  been  no  other  complaint.  Physical  examination  revealed  no  abnor- 
mality in  the  size  or  condition  of  the  liver  or  in  any  other  organ  or 
system,  and  the  child  looked  in  no  wise  ill.  Three  weeks  after  the  onset 
of  the  jaundice  the  child  one  day  became  drowsy,  having  been  previously 
no  worse  than  when  I  saw  her,  and  had  violent  attacks  of  screaming  in 
apparently  causeless  passion.  She  rapidly  became  worse  with  rising 
temperature,  headache  and  frequent  irregular  pulse,  and  died  within 
three  clays  in  general  convulsions  after  several  hours  of  coma.  Nystag- 
mus was  observed  before  coma  set  in,  and  she  vomited  "  coffee-ground  " 
material  twice  during  the  convulsion.  The  lower  edge  of  the  liver  could 
be  felt  the  clay  before  death  but  the  vertical  hepatic  dulness  was  then 
apparently  diminished.  The  liver  only  could  be  examined  post-mortem. 
It  was  of  a  dark  gamboge  colour,  flabby  and  easily  lacerable,  and  weighed 
14^  oz.  Its  section  showed  under  the  microscope  that  the  cellular 
hepatic  structures  had  disappeared,  only  the  portal-canal  system  being 
discoverable.  There  was  also  considerable  fatty  degeneration.  The 
capsule  was  smooth  and  thin.  This  case  perhaps  bears  out  the  view  of 
some  that  the  fatal  toxaemia  in  this  disease  may  be  due  to  ptomaines 
and  leucomaines  accumulating  in  the  hepatic  ducts,  and  that  thus  it 
may  be  secondary  to  ordinary  jaundice  of  congestive,  catarrhal,  or  even 
calculous  origin. 

In  another  case  aged  2^  years,  of  11  days'  duration,  the  symptoms 
were  very  similar,  there  being  nothing  during  the  first  week  or  more  to 
differentiate  them  from  those  of  "simple"  jaundice.  The  liver  was 
enlarged  and  tender  until  a  few  days  before  death  when  its  edge  was  no 
longer  felt.  The  temperature  rose  and  the  child  died  with  convulsions 
and  coma  and  a  temperature  of  1070  F.  Just  before  death  there  was 
vomiting  of  a  coffee-ground  material.  The  liver  was  found  after  death  to 
be  quite  covered  by  the  ribs,  15  oz.  in  weight  (not  therefore  abnormally 


94         DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

light),  of  a  deep  orange  colour  and  very  flabby.  The  bile-ducts  were 
all  patent.  The  stomach  contained  about  8  oz.  of  dark  grumous  fluid. 
Leucin  and  ty rosin  were  found  in  the  liver.  Microscopically  tbere  was 
no  trace  of  normal  liver-tissue  although  the  portal  system  and  hepatic 
veins  were  recognizable.  The  rest  of  the  lobules  were  made  up  of  dis- 
organized and  granular  remains  of  liver  cells  and  connective  tissue 
debris.  In  a  few  places  there  were  collections  of  round  indifferent  cells, 
chiefly  about  the  portal  side  of  the  lobules.  In  this  case  the  correct 
diagnosis  was  not  made  until  shortly  before  death. 

Diseases  of  the  liver  itself  are  not  prominent  in  childhood  and  are 
marked  by  little  that  is  special  to  our  subject. 

Fatty  liver,  with  or  without  enlargement  demonstrable  during  life, 
is  frequent  in  tuberculosis  and  occurs  also  in  connection  with  rickets 
and  chronic  diarrhoea,  and  in  grave  cases  of  scarlet  fever,  diphtheria 
and  other  diseases,  especially  when  there  has  been  prolonged  pyrexia. 
There  are  no  special  clinical  symptoms  of  this  condition  in  children  any 
more  than  in  adults,  and  it  may  exist  in  its  lesser  degrees  with  fairly 
good  health. 

Lardaceous  liver,  mostly  in  common  with  a  similar  affection  of  the 
spleen  and  often  of  the  kidneys  and  intestines,  is  perhaps  the  next  most 
frequent  affection  and  occurs  in  tuberculosis  with  or  without  bone 
disease,  in  suppurative  bone-disease  especially  of  the  hip-joint  and  spine, 
in  syphilis,  and  sometimes  after  prolonged  suppuration  independent  of 
bone-mischief  such  as  an  uncured  empyema.  Of  late  years,  however, 
lardaceous  disease  from  this  last  named  cause  has  become,  I  believe, 
very  rare,  owing  probably  to  prompt  and  effective  treatment  by  resection 
of  the  rib  in  operating  for  empyema.  Lardaceous  disease  causes  far 
greater  enlargement  of  the  liver  than  fatty  or  other  changes,  the  organ 
remaining  about  the  normal  shape  and  being  hard  and  smooth  to  the 
touch. 

Interstitial  hepatitis  or  cirrhosis  is  certainly  rare  in  childhood, 
especially  in  the  form — ending  in  irregular  contraction  of  the  liver — 
which  is  common  in  adults  and  mostly  due  to  alcoholic  excess.  I  have, 
however,  seen  two  cases  in  children  of  three  and  four  years  old  where 
both  the  typical  clinical  symptoms  and  signs  and  the  history  of  either 
much  beer-  or  spirit-drinking  rendered  the  diagnosis  quite  clear,  and  a 
few  cases  bave  been  reported  with  post-mortem  corroboration.  The  large 
cirrhotic  liver  with  jaundice  and  with  or  without  ascites  is  more  common 
in  childhood,  and  this  change  is  sometimes  found  after  death,  especially 
from  the  acute  exanthemata,  when  there  have  been  no  symptoms  referable 
to  hepatic  disorder  during  life.  In  syphilis  and  tuberculosis  also  cirrhotic 
change  in  the  liver  often  occurs  to  a  greater  or  less  degree  with  or  with- 
out symptoms,  and  especially  in  syphilis  the  liver  may  be  acutely  tender 


ASCITES,  JAUNDICE  AND  DISEASES  OF  LIVER.  9  5 

from  perihepatitis.  It  may  be  said  further  in  this  context  that  both 
miliary  and  caseous  tubercle  is  often  found  in  the  liver  of  children, 
sometimes  with  much  enlargement  of  the  organ  which  was  evident 
during  life  with  or  without  some  jaundice,  but  more  often  with  no 
abnormal  physical  signs,  and  that  general  syphilitic  disease  of  the  liver 
often  with  considerable  enlargement  and  hardness  and  much  cell-growth, 
or  discrete  gummata  with  varying  degrees  of  fibrosis  are  not  seldom  seen 
in  quite  young  infants.  That  infantile  syphilis,  other  signs  of  which 
have  passed  away,  may  be  the  cause  of  some  otherwise  apparently  idio- 
pathic cases  of  cirrhotic  liver  in  children  seems,  from  what  we  know  of 
pathology,  to  be  at  least  probable  though  by  no  means  certain. 

There  is  a  chronic  form  of  enlargement  of  the  liver  with  ascites  of 
which  I  have  seen  several  examples,  mostly  with  symptomatic  recovery 
and  apparently  permanent  enlargement  of  the  organ.  I  have  already 
referred  to  these  cases  under  the  head  of  ascites.  Of  temporary  conges- 
tion of  the  liver  with  some  pain  or  tenderness  and  evidenced  further  by 
slight  jaundice  I  have  seen  several  probable  examples,  and  some  instances 
in  childhood  of  undefined  illness  with  pale  coloured  stools,  digestive  dis- 
turbance, and  constipation  may  perhaps  be  referred,  as  Dr.  West  and 
others  have  said,  to  this  condition.  Certainly  in  many  cases  of  this  kind 
exposure  to  cold  seems  to  be  the  exciting  cause,  and  they  are  specially 
apt  to  occur  in  the  early  spring.  I  would  however  remark  here,  as  I 
further  urge  in  another  context,  that  the  recurrent  and  so-called  bilious 
attacks,  usually  attended  by  headache  and  often  by  vomiting  and  some 
fever,  which  are  often  observed  in  children  over  eight  or  nine  years  of 
age  are  almost  always  instances  of  "migraine,"  and  do  not  in  any  way 
yield  to  treatment  by  warmth  or  to  medicines  which  may  act  on  the 
gastro-intestinal  or  hepatic  functions.  Chronic  enlargement  of  the  liver 
due  to  passive  congestion  and  the  result  of  heart  disease,  especially 
mitral,  is  very  common  in  children,  but  need  only  be  mentioned  here  as 
always  to  be  borne  in  mind  in  diagnosis. 

Tumours  of  the  liver  are  rare  in  childhood  and  have  no  special 
peculiarities.  We  should,  however,  always  remember  the  not  very 
uncommon  occurrence  of  hydatid  disease,  and  the  possibility  of  medul- 
lary sarcoma  and  other  malignant  growths.  Abscess  of  the  liver, 
whether  multiple  from  mischief  in  the  region  of  the  portal  vein,  or 
secondary  to  intestinal  ulceration,  and  sometimes  occurring  in  connexion 
with  empyema  or,  though  very  rarely,  with  the  irritation  of  lumbrici  in 
the  bile-ducts  requires  no  detailed  notice  here. 

In  physically  examining  the  region  of  the  liver  in  cases  of  suspected 
hepatic  mischief  in  childhood  the  much  larger  relative  size  of  the  liver 
in  early  life  must  be  remembered,  such  physiological  largeness  being 
generally  evidenced  by  the  ready  palpability  of  the  edge  of  the  liver  up 


96        DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

to  the  end  of  the  second  year  or  even  later,  while  in  young  infants  the 
enlargement  is  easily  demonstrable  both  by  the  touch  and  by  percussion. 
Besides  this  the  outspreading  of  the  lower  ribs,  which  is  more  or  less 
marked  in  infants  and  especially  in  those  who  are  rickety,  often  exposes 
the  liver  to  such  an  extent  as  to  appear  like  undue  enlargement  to  the 
unpractised  observer.  Pleural  effusion  of  the  right  side  may  also  much 
depress  the  normal  liver,  and  an  enlarged  liver  may  escape  observation, 
without  examination  by  percussion  of  its  upper  limit,  by  being  hidden 
under  the  ribs  or  by  the  abolition  of  its  subhypochondrial  area  of  dulness 
through  liquid  or  gaseous  distension  of  the  abdomen. 

The  question  of  treatment  of  hepatic  affections  in  children  resolves 
itself  mainly  into  that  of  the  benign  forms  of  jaundice  and  of  other 
symptoms  referable  with  more  or  less  probability  to  functional  disorder 
of  the  liver.  Of  the  treatment  of  ascites  which  may  accompany  cirrhosis 
or  other  affections  I  have  already  spoken.  In  all  cases  of  jaundice  where 
there  is  constipation  it  is  well  to  give  laxatives  to  secure  one  or  two  daily 
evacuations.  Saline  or  aloetic  medicines  or  a  combination  of  these  may 
be  given  for  this  purpose,  or  one  or  other  of  the  mineral  waters  such  as 
those  of  Karlsbad  or  Vichy.  The  best  diet  is  that  which  consists  mainly 
or  entirely  of  milk  and  farinaceous  food,  but  in  cases  which  do  not  soon 
recover  a  more  mixed  diet,  including  some  meat,  will  probably  be  neces- 
sary. Our  object  is  to  avoid  irritation  of  the  stomach  and  duodenum, 
and  to  unload  the  venous  circulation  as  much  as  possible  so  as  to  allow 
the  hepatic  functions  to  re-establish  themselves  whether  they  have  been 
arrested  by  catarrh  of  the  ducts  or  engorgement  of  the  blood  vessels.  If 
this  method  fail  we  may  try  repeated  doses  of  calomel  or  grey  powder,  or 
give  alkalies  or  acids.  But  in  curable  cases  a  simple  diet  with  occasional 
mild  aperients  is  probably  all  that  will  be  required. 

I  have  but  little  doubt,  from  some  well-marked  cases  I  have  seen 
both  in  adults  and  children,  that  the  liver,  like  that  of  the  Strassburg 
geese,  may  become  congested  and  enlarged  as  the  result  of  overfeeding 
combined  with  overheating  and  want  of  fresh  air.  With  or  without 
jaundice  there  are  symptoms  of  indigestion,  languor  and  irritability. 
The  treatment  of  such  patients  is  clearly  indicated  as  soon  as  the 
cause  of  their  malady  is  suspected,  and  may  be  rewarded  with  a  marked 
degree  of  success. 


KNLARGEMENT  OF  THE  SPLEEN.  97 


CHAPTER  XI. 

ENLARGEMENT    OF   THE   SPLEEN. 

In  childhood  the  spleen  is  apt  to  become  chronically  enlarged  in  various 
general  affections  of  which  the  most  common  are  syphilis,  tuberculosis 
and  lardaceous  disease.  Leucocythaemia  accounts  for  a  few  cases,  as  also 
does  malaria  of  which  I  have  seen  several  definite  examples  in  children 
horn  and  bred  in  the  close  neighbourhood  of  the  London  Thames.  The 
spleen  is  enlarged  in  many  cases  of  rickets,  but  from  the  great  prepon- 
derance of  normal  spleens  in  pure  rickets  I  do  not  regard  this  enlarge- 
ment as  an  integral  part  of  this  disease. 

I  may  also  mention  general  lymphadenoma  as  an  occasional  condition 
in  which  marked  splenic  enlargement  may  arise.  This  affection,  though 
not  rarely  seen  in  childhood,  has  no  claim,  in  any  difference  from  the 
well-known  disease  in  adults,  to  separate  consideration  here.  Enlarged 
spleen  may  also  be  seen  hi  cases  of  chronic  cirrhosis  of  the  liver  or 
otber  obstruction  of  the  portal  vein,  as  well  as  in  some  instances  of 
long-standing  heart-disease.  But  by  far  the  most  frequent  examples 
of  splenic  enlargement  have  in  my  experience  occurred  in  the  ill- 
nourished  children  of  the  poor,  and  are  marked  by  a  waxy  pallor  of 
skin  and  mucous  membranes,  the  blood  being  greatly  deficient  in  red 
corpuscles  but  without  the  character  of  leucocythaemia  as  evidenced 
by  the  haemocytometer.  Doubtless  very  many  of  these  cases  are  the 
subjects  of  rickets,  but,  just  as  we  very  often  find  pronounced  rickets 
without  splenic  enlargement,  so  we  meet  with  numerous  examples  of 
profound  anaemia  with  enlarged  spleen  without  any  evidence  whatever 
of  rickets.  Among  my  hospital  cases  syphilis  occurs  in  many  histories, 
but  nevertheless  its  possible  or  probable  absence  is  sufficiently  frecpient 
to  throw  considerable  doubt  on  its  claim  to  any  essentially  ^etiological 
position.  In  this  affection,  which  is  often  though  by  no  means  always 
fatal  either  from  intercurrent  lung-  or  other  inflammation  or  from 
wasting  with  or  without  peritoneal  dropsy,  the  spleen  is  found  post- 
mortem to  be  large,  hard,  tough  and  simply  hypertrophied,  and,  though 
sometimes  the  lymphatic  glands  and  the  liver  may  be  more  or  less 
enlarged,  no  other  morbid  condition  can  be  demonstrated  in  many  cases. 
The  enlargement  of  the  spleen  occurs  in  all  degrees,  varying  from  a  size 
of  bare  palpability  to  a  visible  tumour  which  may  occupy  more  than  the 
left  half  of  the  abdomen.     My  experience  of  many  of  these  cases  is  in 

G 


98        DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

accord  with  Henoch's  that  their  origin  is  mostly  insidious  and  that  the 
splenic  enlargement  and  pallor  may  have  advanced  to  a  great  degree 
before  wasting,  ascites  or  any  marked  digestive  disturbance  is  observed. 
(Edema  of  the  feet,  hands  or  eyelids  and  sometimes  of  the  body  gene- 
rally has  occurred  more  or  less  in  several  of  my  cases,  and  sometimes 
there  has  been  a  small  purpuric  eruption  or  a  tendency  to  epistaxis  or 
other  haemorrhages  ;  but  it  is  in  the  much  rarer  cases  of  true  and  always 
fatal  leucocythcemia  which  may  sometimes  be  demonstrated  before  the 
pallor  becomes  very  marked,  that  such  haemorrhages  take  place.  I  have 
seen  retinal  haemorrhages  in  two  cases  of  this  latter  disease  in  children 
under  three  years  old. 

Children  suffering  from  this  "  splenic  anaemia  "  in  a  marked  form  are 
usually  drowsy  and  very  apathetic.  Sometimes  the  liver  is  enlarged 
as  well  as  the  spleen.  In  one  case  of  mine  aged  four  years,  where 
the  corpuscular  richness  was  reduced  to  one  half  of  the  normal,  both 
spleen  and  liver  were  large  and  hard.  There  was  absolutely  no  history 
or  suspicion  of  other  disease  and  the  attack  had  begun  three  weeks 
before  admission  with  shivering,  vomiting,  diarrhoea,  headache  and  some 
delirium.  On  admission  there  was  a  slight  rise  of  temperature  which 
soon  subsided,  and  much  sweating.  Eecovery  was  far  advanced  on 
discharge.  Although  the  ultimate  prognosis  in  profound  anaemia  with 
much  splenic  enlargement  is,  according  to  my  own  hospital  experience, 
most  often  bad,  yet  several  cases  live  on  for  some  years,  and  some, 
as  Henoch  records  and  I  have  myself  seen,  seem  to  recover  completely 
from  all  signs  and  symptoms  of  this  affection.  An  interesting  and 
valuable  account  of  a  series  of  thirty  cases  from  his  practice  at  the 
Victoria  Hospital  for  Children  in  Chelsea  was  brought  by  Dr.  J.  W. 
Carr  before  the  Medical  Society  of  London  in  February  1892.  Thir- 
teen either  greatly  improved  or  recovered  with  apparent  complete- 
ness, both  the  blood  and  the  spleen  regaining  their  normal  character 
even  in  several  instances  where  the  spleen  had  been  very  large  and  the 
anaemia  excessive ;  while  ten  were  known  to  have  died  either  from 
increasing  anaemia,  exhaustion  or  intercurrent  disease,  and  one  after  two 
years  was  in  statu  quo.  The  rest  could  not  be  traced.  Most  of  those 
which  recovered,  Dr.  Carr  informs  me,  were  seen  as  out-patients  (and 
therefore  probably  more  or  less  early  in  the  affection)  while  the  fatal 
cases  were  mainly  in  the  Avards.  My  own  noted  cases  being  exclusively 
in-patients  were  comparatively  severe  and  most  of  them  either  showed 
but  little  improvement  or  died.  Dr.  Carr  found  either  certain  or  pro- 
bable evidence  of  syphilis  in  14  cases,  7  of  which  died.  Most  of  them 
were  more  or  less  rickety  but  there  was  no  connexion  between  the 
severity  of  the  rickets  and  the  size  of  the  spleen  or  amount  of  anaemia. 
In  some  of  the  more  severe  cases  haemorrhages  and  irregular  attacks  of 


ENLARGEMENT  OF  THE  SPLEEN.  99 

pyrexia  had  occurred.  In  seven  necropsies  the  spleen  was  firm,  dark 
and  more  or  less  hard,  and  the  microscope  showed  only  simple  hyper- 
trophy with  some  increase  of  fibrous  tissue.  There  was  no  noteworthy 
change  elsewhere. 

I  have  treated  nearly  all  my  cases  with  arsenic  and  iron  and  many 
with  quinine  as  well,  duly  insisting  on  warmth  and  attending  to  nutri- 
tion. In  some  few  cases  I  have  seen  rapid  improvement  set  in  coin- 
cidently  with  the  arsenic  and  iron  treatment  after  long  periods  of 
deterioration  or  of  at  least  no  favourable  progress.  Dr.  Carr  gives  the 
preference  to  iron  over  all  other  drugs.  Whenever  syphilis,  malaria  or 
lardaceous  disease  be  evidenced  or  suspected  appropriate  treatment  must 
be  undertaken  when  possible ;  and  in  all  cases  the  patients  should  be 
amply  supplied  with  fresh  air  and  light. 

It  seems  probable  that  the  splenic  functions  are  exceedingly  active 
in  early  life  and  that  consequently  affections  of  this  organ  are  more 
frequent  then  than  at  later  periods,  but  as  we  are  in  possession  of  no 
exact  knowledge  of  the  nature  of  the  part  played  by  the  spleen  either 
in  the  making  or  the  modifying  of  the  blood  or  in  other  physiological 
processes  it  would  be  unpractical  in  a  clinical  work  to  discuss  the  ulti- 
mate aetiology  of  the  disorder  we  are  considering.  We  must  be  content 
with  the  title  of  "splenic  anaemia"  without  necessarily  attributing  the 
anaemia  to  primary  enlargement  of  the  spleen,  and  may  provisionally 
regard  the  "  symptom-complex  "  as  an  expression  of  bad  nutrition  perhaps 
rather  especially  favoured  by  syphilis.  It  must  be  remembered  as  bearing 
on  the  aetiological  question  that  almost  all  the  cases  occur  within  the 
first  three  years  of  life,  much  the  largest  majority  in  the  first  year  and  a 
half,  and  many  in  the  first  six  months.  Dr.  Carr's  youngest  case  was 
two  months  old  when  first  seen,  and  the  oldest  was  2\  years. 

Of  more  or  less  acute  enlargements  of  the  spleen  we  find  examples  in 
enteric  fever  as  well  as  in  some  other  febrile  diseases.  I  have  occasion- 
ally noticed  in  acute  lobar  pneumonia  considerable  splenic  enlargement 
which  receded  on  the  patient's  recovery.  Enlargement  may  also  occur 
in  connexion  with  embolism  in  the  spleen,  and  especially  in  ulcerative 
endocarditis. 

I  woidd  state  in  conclusion  that  by  "  enlargement  of  the  spleen " 
I  mean  an  enlargement  which  can  be  readily  demonstrated  by  careful 
palpation ;  for  in  children  much  more  than  in  adults  the  results  of 
percussion  alone  are  seldom  to  be  trusted  as  evidence.  The  resistance 
moreover  of  the  abdominal  walls  and  gastric  or  intestinal  distension  often 
make  it  difficult  to  detect  an  enlargement  easily  recognizable  in  other 
conditions.  An  enlarged  spleen  can  usually  be  distinguished  from  other 
tumours  either  by  feeling  its  notch,  or  by  carefully  observing  its  position 
and  noting  that  it  rises  and  falls  with  the  moving  diaphragm.     It  must 


100        DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

always  be  remembered  that  thoracic  deformity  or  left  pleural  effusion  or 
other  conditions  that  may  displace  the  diaphragm  may  cause  a  healthy 
spleen  to  become  palpable. 


CHAPTER  XII. 

URINARY    DISORDERS. 

The  quantity  and  quality  of  the  urine  vary  more  within  the  bounds  of 
health  in  early  childhood  than  in  later  life.     Heat  and  cold  produce 
comparatively  greater  degrees  of  scantiness  and  profuseness  of  flow,  and 
the  imperfect  stability  of  the  nervo-muscular  mechanism  of  urination  is 
probably  a  not  infrequent  cause  of  marked  quantitative  variations.     Urea 
is  excreted  in  relatively  larger  amounts  than  in  adults,  and  lithates  are 
more  often  seen  as  a  deposit  owing  not  only  to  excess  from  a  probably 
overdue  amount  of  food,  but  also  to  diminution  of  the  proportion  of 
urinary  water.     Uric  acid  often  appears  in  the  urine  without  any  symp- 
toms of  ill  health,  as  the  result  not  only  of  concentration  but  also  of 
temporary  hyperacidity  of  the  urine,  or  from  excess  of  nitrogenous  food. 
When  however  marked  quantitative  or  qualitative  abnormalities  are  ob- 
served for  any  length  of  time  search  should  be  made  for  morbid  causes. 
Polyuria  may  result  from  some  dietetic  errors  or  digestive  disorder, 
barley-water  being,  according  to  Eustace  Smith,  a  cause  in  some  children. 
Ordinary  diabetes  is  very  rare.     I  have  very  little  personal  experience 
of  this  disease  in  childhood,  and  have  never  seen  a  case  in  my  practice 
at  the  Hospital  for  Children.    Authorities  on  the  matter  agree  that  diabetes 
is  rapidly  fatal  in  early  life  and  often  hereditary,  and  it  is  believed  by 
some  that  it  has  a  close  connexion  with  hereditary  phthisis  and  struma. 
A  case  I  once  saw,  of  about  10  years  old,  died  with  coma  two  months 
after   the   symptoms  were  first  observed,  the   polyuria  and  glycosuria 
having  much  decreased  under  orthodox  treatment.     A  similar  case  is 
reported  in  detail  by  Dr.  G-.  B.  Fowler  in  Keating's  Cyclopcedia  of  the 
Diseases  of  Children.     The  so-called  "  diabetes  insipidus,"  where  a  flow 
of  watery  urine  of  very  low  specific  gravity  takes  place  out  of  all  pro- 
portion even  to  the  copious  ingestion  of  fluids  prompted  by  thirst,  is 
more  often  met  with.     Such  cases  are  sometimes,  though  rarely,  known 
to  follow  on  injuries  or  organic  disease  of  the  brain,  but  more  are  con- 
nected with  functional  nervous  disturbance,  and  most  which  have  come 
under  my  care  with  this  diagnosis,  suffering  perhaps  from  some  debility 
or  other  indefinite  complaints,  have  shown  little  or  no  evidence  whatever 


URINARY  DISORDERS.  10 1 

of  the  affection  when  placed  under  the  ordinary  routine  of  hospital  treat- 
ment without  special  diet  or  medicine.  In  obstinate  cases,  however, 
valerian,  or  the  valerianate  of  zinc  recommended  as  useful  by  Trousseau 
and  Sir  William  Roberts,  may  be  tried.  Before  regarding  any  case  as 
diabetes  insipidus  we  must  remember  that  polyuria  may  result  from 
chronic  renal  disease  of  which  I  have  seen  two  instances,  at  first  sight 
simulating  diabetes,  where  albuminuria  was  slight  and  frequently  absent, 
and  also  from  hydronephrosis  of  congenital,  calculous,  or  other  obstructive 
origin,  in  which  it  may  be  observed,  as  shown  by  one  of  my  cases,  before 
there  is  any  abdominal  distension  or  evidence  of  renal  enlargement.  In 
the  case  referred  to  both  kidneys  were  greatly  enlarged  from  pelvic  dis- 
tension, and  the  mucous  membrane  of  the  bladder  much  trabeculated, 
with  numerous  haemorrhages.  Towards  the  end  there  was  some  albumi- 
nuria and  occasional  hematuria.  Oliguria  or  even  temporary  anuria  is 
often  seen  with  profuse  diarrhoea,  vomiting,  great  exhaustion  from  in- 
sufficient food,  various  febrile  states,  excess  of  uric  acid  in  the  urine, 
and  in  renal  mischief  with  or  without  dropsy,  and  either  primary,  or 
secondary  to  cardiac  disease. 

Enuresis  or  incontinence  of  urine,  although  in  children  rarely  due  to 
local  trouble,  is  from  a  practical  point  of  view  best  treated  in  this  con- 
text. In  infancy  this  condition  is  physiological,  the  urinary  reflex  not 
being  as  yet  under  the  control  of  the  brain.  In  some  children  this 
imperfection  of  control  lasts  far  beyond  the  normal  period,  and  when 
not  distinctly  referable  to  deficient  training  and  habit  or  marked  local 
irritation  is  usually  connected  with  other  signs  of  nervous  instability. 
Not  only  does  it  occur,  sometimes  in  an  obstinate  form,  in  those  who 
suffer  from  night  terrors  or  epilepsy,  but  in  greater  or  less  degree  it  is 
frequently  observed  in  stammerers,  in  those  apt  to  start  and  tremble  at 
slight  causes  and  in  emotional  children  generally.  Often  it  may  occur 
after  some  definite  occasions  of  excitement.  In  many  instances  the 
affection  begins  from  various  causes  in  early  childhood  after  normal 
control  has  been  acquired.  According  to  Goodhart  there  is  a  special 
liability  to  it  in  members  of  rheumatic  families,  affording  one  illustration 
out  of  many  others  of  the  neurotic  relationships  of  acute  rheumatism. 
The  conventional  reference  of  this  phenomenon  to  spasm  of  the  detrusor 
or  atony  of  the  sphincter  muscles  is  little,  if  anything,  more  than  a  tauto- 
logical statement  neither  explanatory  nor  therapeutically  helpful.  In 
the  worst  cases  incontinence  is  diurnal  as  well  as  nocturnal,  but  all  are 
usually  curable  alike  by  care  and  psychical  treatment,  except  where  there 
is  local  malformation  and  in  some  few  where  there  may  be  a  marked 
hereditary  tendency  to  this  special  complaint.  In  the  majority  of  in- 
stances incontinence  occurs  only  during  sleep,  when  any  undue  reflex 
excitability  of  the  bladder  is  unantagonized  by  the  extra  contraction 


102        DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

of  the  sphincter  accompanying  voluntary  impulse  in  the  waking  state. 
When  the  incontinence  is  also  diurnal  we  may  infer  some  derange- 
ment of  the  nervo-muscular  apparatus  of  urination  which  is  frequently 
referable,  in  the  absence  of  local  trouble  or  detectable  cause  of  peripheral 
irritation,  to  imperfect  nervous  control  over  the  sphincter.  My  expe- 
rience has  taught  me  that,  when  local  mischief  can  be  excluded,  almost 
all  obstinate  or  really  intractable  cases  of  incontinence  of  urine  by  day 
as  well  as  by  night  are  marked  by  some  degree  of  mental  abnormality. 
Apart  from  cases  due  to  bad  training  which  are  usually  cured  with  ease 
the  affection  is  perhaps  most  frequent  in  boys  although  its  worst  instances 
occur  certainly  much  more  often  in  girls.  The  difference  is  probably  due 
on  the  one  hand  to  more  multiform  sources  of  peripheral  irritation  in  boys 
and  on  the  other  to  a  greater  liability  to  nervous  disturbance  in  girls. 

The  common  nocturnal  form  of  incontinence  may  occur  every  night  or 
at  longer  and  irregular  intervals,  and  it  is,  according  to  many  observers, 
especially  apt  to  take  place  soon  after  going  to  bed  or  early  in  the  morn- 
ing— periods  when  although  the  higher  control  is  in  abeyance  yet  reflex 
irritability  is  less  profoundly  affected  than  in  the  deepest  sleep.  How- 
ever this  may  be  at  least  many  cases  are  soon  curable  by  being  waked 
up  and  encouraged  to  urinate  within  a  few  hours  after  going  to  sleep, 
the  time  being  fixed  in  each  instance  after  careful  observation,  and  by 
a  second  arousal  early  in  the  morning. 

Causes  of  irritation  leading  to  the  necessity  of  frequent  urination 
should  always  be  searched  for  and  removed  when  possible.  Such 
are  too  much  drinking,  hyperacidity  of  urine,  the  presence  of  uric 
acid,  probably  late  and  improper  meals,  renal  mischief  both  nephritic 
calculous  and,  though  very  seldom,  hydronephrotic,  and  stone  in  the 
bladder.  Diabetes  insipidus  must  also  be  thought  of.  Threadworms 
in  the  lower  bowel  and  other  rectal  troubles  are  often  excitants,  as 
also  is  vulvitis,  or  preputial  irritation  especially  with  adhesion  or 
marked  phimosis.  I  do  not,  however,  think  that  a  long  and  tight  fore- 
skin apart  from  a  high  degree  of  phimosis  is  so  common  a  source  as 
many  seem  to  assume.  Several  protracted  cases  of  enuresis  previously 
circumcised  with  therapeutic  design  have  come  before  me,  and  I  have 
seen  many  children  with  very  contracted  preputial  opening  and  no  ten- 
dency to  incontinence.  Few  cases  last  beyond  the  period  of  puberty 
even  when  neglected. 

The  proper  treatment  of  enuresis  is  partially  pointed  out  by  the  con- 
sideration of  possible  exciting  causes.  In  nocturnal  cases  late  meals  and 
especially  late  drinking  in  any  quantity  should  be  avoided,  alkaline 
medicines  given  if  the  urine  be  very  acid,  and  all  urinary  and  other 
indications  duly  attended  to  after  careful  examination  of  the  case.  The 
child  should  always  be  awaked  at  regular  intervals  during  the  night  to 


URINARY  DISORDERS.  103 

pass  water,  and  should  be  incited  by  any  means  other  than  punishment 
to  make  efforts  to  bruak  the  habit.  Most  cases  are  thus  cured  without 
drugs  in  a  short  time,  as  is  amply  evidenced  in  hospital  practice.  In 
many  instances  however  and  notably  in  those  where  the  incontinence  is 
also  diurnal  general  tonic  treatment  both  hygienic  and  medicinal  is  of 
indispensable  value  even  when  all  psychical  methods  have  more  or  less 
failed.  I  have  no  belief  that  strychnia  cures  by  its  alleged  action  on  the 
sphincter  of  the  bladder  but  with  iron  or  arsenic  it  is  probably  a  very 
helpful  drug.  I  have  so  signally  failed  to  produce  any  probably  good 
effect  with  belladonna  that  I  am  constrained  in  the  face  of  most  autho- 
rity to  the  contrary  to  pronounce  at  least  against  its  frequent  usefulness. 
I  have  never  known  improvement  from  it  in  cases  with  otherwise  un- 
altered conditions,  nor  on  the  other  hand  in  those  to  whose  previously 
careful  but  unsuccessful  treatment  it  formed  the  sole  addition.  I  have 
pushed  it  in  many  simple  cases,  afterwards  cured,  as  far  as  any  of  its 
advocates  could  wish,  and  have  moreover  incidentally  found  that  symp- 
toms of  poisoning  are  by  no  means  so  hardly  produced  in  young  children 
as  many  modern  authorities  allege.  In  many  cases,  and  especially  when 
there  is  marked  excitability,  a  temporary  course  of  nervine  sedative 
medicines  such  as  the  bromides,  opium  or  other  drugs,  an  extra  dose 
being  given  at  night,  may  be  tried,  and  often  meets  with  marked  success. 
In  such  cases  belladonna  has  probably  gamed  some  of  its  credit.  The 
worst  case  that  I  have  ever  seen  recover  was  that  of  a  girl  fourteen 
years  old  who  had  suffered  all  her  life  and  whose  mother  and  uncle 
had  been  similarly  affected  until  beyond  the  period  of  childhood.  I 
treated  her  for  two  weeks  at  home,  giving  careful  instructions  to  the 
mother  and  rapidly  pushing  belladonna  till  throat  symptoms  and  a 
rash  appeared.  She  was  then  admitted  unimproved  into  a  private 
hospital,  where  with  dry  diet,  direct  instruction,  routine  living  and 
neither  medical  visits  nor  drugs  she  became  rapidly  better  and  was 
permanently  cured  in  one  month. 

Copious  and  continued  deposit  of  urates,  especially  when  accom- 
panied by  crystals  of  uric  acid,  is  not  seldom  attended  by  symptoms  both 
local  and  general  and  may  indicate  a  tendency  to  calculous  formation 
in  the  urinary  tract.  The  vexed  question  of  the  ultimate  pathology  of 
those  cases  where  there  is  an  actual  excess  of  uric  acid  excretion,  being 
outside  the  domain  of  renal  disorder  and  involving  the  consideration  of 
hepatic  and  other  functions,  need  not  here  be  discussed,  but  it  must  be 
remembered  that  the  symptoms  of  so-called  "lithsemia"  or  "lithiasis" 
are  any  or  all  of  them  frequently  met  with  in  children  and  are  often 
connected  with  marked  deposits  of  urates  and  uric  acid.  Such  are  dis- 
turbed digestion  with  coated  tongue,  pains  in  the  limbs  and  head,  tooth- 
grinding,  irritability  of  temper  and  drowsiness  followed  by  sleeplessness. 


104        DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

These  attacks  are  often  the  sequelee  of  excessive  or  indiscreet  feeding 
and  are,  I  think,  frequently  seen  in  children  of  distinct  gouty  heredity. 
They  are  also  doubtless  frequent  in  strumous  and  neurotic  town  children 
who  are  the  victims  of  want  of  fresh  air  and  exercise.  It  must  be 
remembered  that  uric  acid  infarcts  are  sometimes  found  in  the  kidneys 
of  recently  born  infants  and  that  uric  acid  gravel  is  often  seen  as  a 
deposit  in  the  urine  of  quite  young  babies,  becoming  less  frequent  as 
age  advances.  Up  to  a  certain  point  such  a  deposit  is  physiological,  and 
it  is  further,  as  all  observers  know,  quite  common  to  find  uric  acid 
gravel  from  time  to  time  in  the  urine  of  children  before  the  age  of 
puberty  with  few  or  no  symptoms.  The  border  line  between  the  physio- 
logical and  the  pathological  is  here  difficult  to  draw,  but  it  may  be 
said  that  frequency  of  this  condition  is  usually  accompanied  by  some 
symptoms,  and  is  mostly  confined  to  distinctly  delicate  children  whose 
system,  owing  probably  to  deficient  blood  oxygenation,  is  not  capable  of 
sufficient  urea  formation.  We  also  frequently  meet  with  cases  of  some- 
what suddenly  occurring  fretfulness  or  screaming  in  infants  and  young 
children  which  may  last  more  or  less  for  a  few  days  and  then  disappear 
rapidly  with  a  copious  discharge  of  highly  acid  urine  loaded  with  urates, 
and  there  are  still  more  severe  attacks  with  great  pain  where  crystals 
of  uric  acid  or  of  urate  of  soda  are  found  in  the  urinary  deposit.  In 
these  cases  there  may  be  frequent  urination  or  occasional  anuria,  and 
the  child  may  complain  of  pain  in  the  lower  part  of  the  abdomen  or  the 
urethra.  As  far  as  the  urinary  phenomena  are  concerned  in  cases  of 
so-called  lithiasis  we  may  find  all  grades  of  severity  between  those 
which  from  their  triviality  and  evanescence  can  scarcely  be  regarded 
as  pathological  and  others  which  are  definitely  recognisable  as  due 
to  calculous  formation  in  the  urinary  tract.  It  is  well  known  that, 
although  other  deposits  may  be  found,  the  calculi  of  children  almost 
always  consist  either  of  uric  acid  or  urate  of  soda.  In  spite,  therefore, 
of  occasional  deposits  of  urates  or  uric  acid  being  of  little  practical 
significance  in  young  children  their  frequent  occurrence  should  not  be 
neglected.  Symptoms  of  discomfort  and  pain,  not  always  in  imme- 
diate connexion  with  the  act  of  urination,  are  common  in  cases  of  this 
kind,  and  heeinaturia  is  an  important  diagnostic  sign  of  probable  cal- 
culous irritation  of  the  urinary  passages.  I  have  notes  of  many  cases 
of  paroxysmal  abdominal  pain  without  hematuria  in  children  otherwise 
healthy  which  led  to  the  discovery  of  crystalline  deposits  in  the  urine, 
relief  or  recovery  being  usually  attained  by  careful  dieting  and  alkaline 
medicine.  In  the  numerous  cases  attended  by  hematuria  we  should 
always  suspect  renal,  ureteric  or  vesical  calculus,  and  even  in  the  absence 
of  hematuria  the  bladder  should  always  be  carefully  and  even  repeatedly 
sounded  when  the  case  is  doubtful. 


URINARY  DISORDERS.  105 

Cases  of  frequent  "  gravel,"  especially  when  accompanied  by  symptoms, 
should  be  dieted  at  regular  intervals  by  small  meals  consisting  of  very 
little  meat,  plenty  of  milk  and  vegetables  and  a  moderate  quantity  of 
farinaceous  food.  Bacon  may  be  given  from  time  to  time.  Sweets 
should  be  avoided.  Citrate  or  acetate  of  potash  should  be  taken  in  such 
doses  as  to  render  the  urine  slightly  alkaline,  for  which  purpose  about 
fifteen  grains  every  four  hours  will  probably  be  sufficient  for  a  child 
about  eight  years  old.  In  cases  where  renal  calculus  is  suspected  or 
diagnosed  this  treatment  must  be  persevered  with  for  several  weeks. 
The  child  should  always  be  made  to  drink  copiously  of  water  which 
must  not  be  hard  and  should  preferably  be  distilled,  and  due  warmth  of 
clothing  and  plenty  of  fresh  air  and  exercise  should  be  insisted  on.  A 
graphic  exposition  of  the  symptoms  of  "  litheemia "  in  children  by  the 
late  Dr.  M.  Fothergill  is  to  be  found  in  vol.  ii.  of  Keating's  Cydopcedia 
of  the  Diseases  of  Children.  Though  somewhat  high-coloured  in  my 
opinion  for  an  accurate  clinical  picture  the  article  is  valuable  owing  to 
the  too  scanty  attention  usually  paid  to  this  subject  by  writers  on 
the  maladies  of  childhood. 

With  regard  to  renal  calculus,  frequent  though  it  be,  there  is  nothing 
peculiar  to  childhood.  I  would  however  emphasize  the  fact  that  in  chd- 
dren  as  well  as  in  adults  the  presence  of  calculus  by  no  means  necessi- 
tates haematuria  nor  even  marked  pain,  and  that  crystalline  deposits 
are  often  absent  from  the  urine.  Pyuria  either  continuous  or  intermittent 
with  more  or  less  frequent  urination  may  be  all  that  is  observed. 

Haematuria  may  occur,  as  in  adults,  from  many  causes,  the  most 
frequent  of  which  by  far  are  crystalline  or  calculous  deposits  in  the 
urinary  tract,  usually  demonstrable  by  microscopical  examination  of  the 
urine.  Most  attacks  of  recurrent  haematuria  in  children  are  preceded  by 
pain  in  the  umbilical,  hypogastric  or  lumbar  region,  and  are  connected 
with  more  or  less  constant  enuresis.  The  pain  and  enuresis  may  how- 
ever occur  without  hasmaturia.  A  careful  examination  and  discovery 
in  the  urinary  deposit  of  crystals  of  uric  acid,  urate  of  soda  or  oxa- 
late of  lime  Avill  sometimes  explain  an  otherwise  mysterious  case  of 
haematuria  attended  by  little  or  perhaps  no  pain,  as  I  have  more 
than  once  found  in  instances  where  patients  had  been  long  treated  by 
styptics  and  other  measures  with  the  diagnosis  of  intermittent  hematuria 
from  hypothetical  causes.  In  this  context  I  may  mention  an  interesting 
case,  lately  reported  to  me  by  Mr.  Scott  Battams,  of  a  little  boy  who  was 
brought  to  him  suffering  from  profuse  haematuria  after  eating  for  several 
days  immoderate  quantities  of  rhubarb  supplied  him  by  his  mother  in 
the  belief  that  it  was  very  good  for  him.  The  extent  and  suddenness 
of  the  bleeding,  which  was  a  first  attack,  prompted  inquiry  as  to  diet  and 
thus  at  once  revealed  the  true  cause — the  oxalate  of  lime  in  the  rhubarb. 


106        DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

The  haeiuaturia  rapidly  and  permanently  disappeared  on  the  discontinu- 
ance of  this  manner  of  feeding.  It  must  always  be  remembered  that 
hsematuria  may  result  from  small  crystalline  deposits  in  the  kidney  as 
well  as  from  those  which  merit  the  title  of  calculus.  My  notes  of 
several  cases  due  either  certainly  or  with  the  greatest  probability  to 
crystalline  or  calculous  deposits  in  the  kidney  show  that  the  affection 
may  recur  for  years  with  more  or  less  protracted  intermissions  but  often 
without  increasing  severity.  Sometimes,  though  rarely,  they  seem  to 
cease  altogether. 

I  do  not  fail,  however,  to  recognise  with  Goodhart  and  others  a  class 
of  cases,  though  I  believe  it  to  be  but  small,  in  which  the  absence  of  all 
signs  and  symptoms  other  than  true  hsematuria  and  at  least  apparent 
recovery  under  ordinary  care  render  a  definite  diagnosis  impossible. 

Haematuria  occurs  also,  though  not  always  and  often  but  slightly,  in 
tuberculous  kidney  and  in  sarcomatous  kidney.  I  have  seen  it  in  three 
cases  of  purpura  and  in  two  of  diphtheria.  Its  most  common  cause, 
however,  apart  from  renal  or  vesical  calculus,  is  acute  nephritis,  whether 
or  not  of  scarlatinal  origin,  when  the  urine  has  usually  a  smoky  tint. 

Blood  which  comes  from  the  bladder  or  ureter,  in  children  almost 
always  due  to  stone,  is  distinguished  from  that  first  shed  in  the  kidney 
by  its  greater  brightness,  less  intimate  intermixture  with  the  urine,  and, 
above  all  tests,  by  the  absence  of  renal  blood-casts  on  microscopical 
examination. 

Hsemoglobinuria  or  the  presence  of  the  colouring  matter,  without  the 
corpuscles,  of  the  blood,  demands  separate  attention  owing  to  its  peculiar 
clinical  relationships,  although  at  least  in  Britain  it  is  by  no  means  a 
common  affection.  This  term  is  to  be  applied  only  to  cases  where  ab- 
sence of  blood  corpuscles  is  established  by  the  microscopical  examination 
of  the  urine  immediately  after  it  is  passed,  for  under  certain  conditions, 
such  as  ammoniacal  urine,  the  corpuscles  may  be  very  soon  destroyed. 
True  haemoglobinuria  implies  hsemoglobineemia  or  at  least  a  partial 
destruction  of  the  circulating  blood,  and  may  occur  in  cases  of  septic  or 
medicinal  poisoning,  chlorate  of  potash  in  large  doses  having  been  espe- 
cially credited  with  its  production.  Of  the  salient,  dangerous  and  mostly 
fatal  example  in  new-born  infants,  sometimes  of  epidemic  character, 
known  as  Infectious  Haemoglobinaemia  or  Winckel's  disease  and  descrip- 
tively styled  by  that  observer  as  "  cyanosis  infantilis  icterica  perniciosa 
cum  hsemoglobinuria"  I  have  no  personal  knowledge,  nor,  as  far  as  I 
know,  is  there  any  important  British  literature  on  this  disease.  A  full 
account  drawn  from  continental  and  American  sources  is  given  by  Dr. 
Griffith  in  vol.  iii.  of  Keating's  Cyclopcedia  of  the  Diseases  of  (Jliildren. 
Its  very  probable  origin  in  some  microbic  poisoning  of  the  blood  is  im- 
portant in  studying  the  cases  of  paroxysmal  haemoglobinuria,  elsewhere 


URINARY  DISORDERS.  I  07 

alluded  to  in  connexion  with  Raynaud's  disease,  which  are  from  time 
to  time  observed  in  children  as  well  as  in  adults,  especially  Avhen  we 
remember  that  probably  the  majority  of  adult  cases  are  of  malarial 
origin.  Paroxysmal  haemoglobinuria,  however,  may  occur  in  children 
without  any  traceable  history  of  malaria  or  other  definite  antecedent 
mischief.  It  is  almost  always  associated  with  some  degree  of  circulatory 
stasis  in  the  extremities  or  ears,  known,  according  to  its  varying  intensity, 
as  local  syncope,  asphyxia  or  gangrene,  but,  since  all  these  latter  pheno- 
mena may  take  place  with  no  urinary  abnormality,  this  form  of  hasmo- 
globinuria  cannot  be  regarded  as  a  substantive  clinical  affection.  The 
urine  in  these  cases,  devoid,  as  has  been  said,  of  blood  disks,  is  of  dark 
port-wine  or  of  porter  colour  and  almost  exclusively  passed  after  exposure 
to  chill  in  some  degree.  My  own  clinical  experience  of  this  affection 
has  been  hitherto  confined  to  adults,  but  undoubted  cases  in  children 
have  been  reported  from  time  to  time.  Dr.  W.  Pasteur  has  kindly  shown 
me  the  notes  of  two  typical  cases  in  girls  aged  6  and  4  respectively, 
occurring  in  his  practice  at  the  North-Eastern  Hospital  for  Children. 
Both  were  of  undetected  origin,  and  the  blood  drawn  from  affected  parts 
of  the  body  at  the  time  of  the  chills  and  the  hsemoglobinuria  was  very 
poor  in  corpuscles  which  were  much  altered  in  character,  crenated  or 
otherwise,  and  showed  little  tendency  to  form  rouleaux.  The  urine  in 
both  cases  contained  crystals  of  oxalate  of  lime  such  as  have  been  found 
in  other  instances.  Cases  in  children  have  been  reported  also  by  Drs.  T. 
Barlow,  J.  Abercrombie  and  others. 

I  have  recently  seen  at  Westminster  Hospital  two  adult  cases,  similar 
to  the  above,  but  both  malarious,  with  signs  of  well-marked  though 
inextensive  past  gangrene  of  the  ear- tips,  and  with  marked  pallor  or 
blueness  of  the  extremities  immediately  preceding  the  appearance  of 
blood  in  the  urine.  Sometimes  there  is  pain  in  the  back  or  abdomen 
during  the  attacks  and  sometimes  there  are  periods  of  pyrexia.  In  both 
of  Dr.  Pasteur's  cases  the  temperature  rose  frequently  to  103°  when  the 
dark  urine  was  passed,  and  was  often  considerably  above  normal  at  other 
times.  The  treatment  of  haematuria  and  of  hsemoglobinuria  must  of 
course  have  respect  when  possible  to  the  ascertained  cause  in  each  case, 
and  is  elsewhere  incidentally  dealt  with.  The  symptom  itself,  from 
whatever  cause  arising,  scarcely  ever  calls  for  attempts  at  styptic  treat- 
ment. When  the  symptoms  are  associated  with  Raynaud's  disease  it  is 
advisable  to  give  quinine,  arsenic  and  iron,  and  in  all'  cases  the  body- 
warmth  should  be  sedulously  maintained. 

Albuminuria  as  a  symptom  of  kidney  disease  will  be  presently  men- 
tioned under  that  heading.  It  may  occur  temporarily  in  many  febrile 
and  infectious  disorders  with  greater  frequency  than  in  later  life,  and  its 
disappearance  very  soon  after  the  patient's  recovery  is  more  often  noted 


108       DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

in  childhood.  A  salient  example  of  this,  among  others,  is  the  frequent 
albuminuria  without  dropsy  or  other  sign  of  nephritis  which  so  often 
accompanies  or  supervenes  on  scarlatina.  Albumen  may  be  also  caused 
by  the  presence  of  pus  in  the  urine  derived  from  the  urethra  or  from 
leucorrhcea  and  inflammatory  conditions  of  the  vulvo-vaginal  passage, 
from  the  irritation  of  vesical  and  renal  calculus,  and  from  tuberculous 
or  sometimes  malignant  disease  of  the  kidneys ;  by  haematuria  and 
haemoglobinuria ;  by  chyluria ;  and  by  pressure  on  the  renal  vessels  from 
tumours  in  the  abdomen. 


CHAPTER  XIII. 

ON   ANASARCA    AND    KIDNEY    DISEASE. 

Anasarca  more  or  less  general  but  especially  affecting  the  eyelids  and 
extremities  is  the  leading  symptom  of  kidney  disease  in  infants  and 
children,  the  chronic  nephritis  of  contracting  kidney  without  dropsy 
which  is  so  common  in  adults  being  but  rarely  seen  in  early  life. 
Before  speaking  of  kidney  disease  I  shall  dwell  shortly  on  certain  con- 
ditions apart  from  nephritis  or  at  least  without  any  evidence  of  its 
presence  in  which  marked  anasarca  similar  to  that  of  kidney  disease 
is  observed. 

We  not  rarely  meet  with  general  anasarca,  without  albumen  or  casts 
in  the  urine,  which  may  be  of  considerable  duration  but  is  shown  in 
fatal  cases  to  be  unconnected  with  renal  disease.  It  must  be  insisted 
on  however  that  many  of  these  cases  are  completely  indistinguishable 
from  renal  dropsy  during  life,  that  it  is  only  a  careful  microscopical 
examination  of  the  kidneys  that  can  exclude  disease,  and  that,  as  Henoch 
and  others  have  shown,  there  are  undoubted  cases  of  readily  recognized 
nephritis  which  have  not  been  evidenced  by  any  abnormality  of  the 
urine.  It  is  especially  anaemia  in  its  various  forms,  splenic  and  other- 
wise, leucocythsemia,  cardiac  weakness,  diarrhoea  and  exhausting  pul- 
monary affections  in  which  anasarca  without  albumen  or  casts  in  the 
urine  is  apt  to  occur.  Many  of  these  cases,  of  course,  may  recover 
perfectly.  Most  authors  agree  in  stating  that  dropsy  without  albumen 
or  casts  in  the  urine  may  occasionally  occur  after  scarlet  fever ;  and  the 
same  sequela  is  seen  after  other  acute  diseases,  mostly  connected  with 
considerable  anaemia.  I  have  seen  also  in  weakly  infants  several  cases 
of  extensive  anasarca  generally  fluctuating  much  in  quantity  where  there 
had  never  been  any  albuminuria  and  where  after  death  only  slight  renal 


ANASARCA  AND  KIDNEY    DISEASE.  109 

congestion  was  found.  Thus  a  child  who  had  had  convulsions  from 
birth  and  jaundice  for  three  weeks,  and  never  seemed  well,  had  general 
dropsy  at  the  age  of  three  months ;  the  urine  was  very  pale  and  became 
scanty  shortly  before  death  at  the  age  of  4^  months.  The  child  was 
wet-packed  and  treated  with  hot-air  baths  with  no  good  effect.  In 
another  child,  admitted  at  the  age  of  14  months  with  very  variable 
anasarca  and  urinary  flow,  the  attack  had  begun  recently  and  suddenly 
with  dark  urine  after  four  months  of  illness  and  wasting  following 
varicella.  There  was  great  anaemia  but  no  splenic  enlargement  and  no 
qualitative  change  in  the  urine.  In  spite  of  care  and  treatment  the 
child  died  two  weeks  after  admission.  Nothing  was  found  post-mortem 
in  either  case  but  a  little  renal  congestion  and  slight  collapse  of  lungs. 

General  anasarca  without  albuminuria  sometimes  occurs  after  inflam- 
matory skin  affections  such  as  erysipelas  and  urticaria.  I  have  also 
seen  two  cases  of  extensive  dropsy  with  albuminuria  and  scanty  urine 
in  immediate  connexion  with  severe  acute  urticaria.  In  one,  which  was 
a  single  attack,  all  symptoms  completely  disappeared.  In  the  other, 
possibly  of  a  different  nature,  there  had  been  several  exactly  similar 
attacks  during  one  of  which  there  were  under  my  observation  repeated 
uraamic  convulsions  with  pericarditis  and  pleurisy.  Slight  albumen 
without  casts  in  the  urine  remained  after  otherwise  good  recovery. 

Acute  nephritis  in  children  is  undoubtedly  most  often  of  scarlatinal 
origin,  and  may  occur  at  periods  varying  from  one  to  four  weeks  or  more 
after  the  onset  of  the  disease.  It  is  mostly  evidenced  by  dropsy,  nearly 
always  by  albuminuria  and  the  presence  of  epithelial  or  hyaline  casts 
in  the  urine,  and  very  often  by  more  or  less  hsernaturia.  Shortness  of 
breath  in  some  degree  is  mostly  present  and  sometimes  there  is  a  little 
fever.  Vomiting  at  the  outset  is  frequent  and  may  be  repeated.  Irre- 
gularity and  slowing  of  the  heart-beats,  obscuration  of  the  first  sound  or 
a  systolic  apex  murmur,  and  accentuation  of  the  second  sound,  especially 
at  the  aortic  cartilage,  are  often  to  be  observed.  Great  pallor  of  the  skin 
almost  always  obtains,  and  in  many  cases,  especially  after  scarlatina,  this 
pallor,  and  oedema  of  the  eyelids,  hands  and  feet  are  the  first  symptoms 
complained  of,  and  lead  to  the  detection  of  scanty  urine  containing 
albumen  or  perhaps  some  blood.  In  some  cases  nephritis  is  distinctly 
evidenced  by  albuminuria,  casts,  leucocytes  and  epithelial  cells  when 
the  urine  is  not  scanty  and  there  is  little  or  no  oedema.  The  specific 
gravity  of  the  urine  is  usually  low.  Headache  is  a  very  common  symp- 
tom, and  there  is  generally  constipation  though  occasionally  diarrhoea. 
Fever  is  sometimes  absent  throughout  the  attack,  and  is  scarcely  ever 
high  in  nephritis  without  other  complications.  Urasmic  symptoms,  as 
in  adults,  may  occur  at  any  time,  are  not  necessarily  connected  with 
very  scanty  urine  or  marked  dropsy  and  may  be  followed  by  complete 


I  I O       DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

recovery.  Pleurisy  and,  still  more,  pericardial  effusion  are  usually  of 
late  occurrence  and  very  serious  significance.  (Edema  of  lungs,  fauces, 
and  glottis  are  also  signs  of  great  danger.  Ascites  is  mostly  a  somewhat 
grave  expression  of  the  disease  but,  nevertheless,  often  disappears.  Acute 
pleuritis,  pericarditis  and  peritonitis  may  each  or  all  take  place,  but 
generally  in  fatal  cases.  Although  in  every  case  of  acute  nephritis  in 
children  safe  practice  requires  us  to  inquire  and  examine  for  evidence 
of  antecedent  scarlatina,  we  must  remember  that  the  disease  may  occur 
with  diphtheria,  measles,  some  forms  of  pneumonia  and  other  fevers, 
and  may  accompany  the  septic  diarrhoea  of  infants  which  is  so  common 
in  the  hot  weather.  It  is  moreover  sometimes  found  in  children  a  few 
weeks  old.  I  am  convinced  from  experience  of  many  cases  that  acute 
nephritis  is  not  at  all  rare  in  young  children,  not  only  when  there  is  abso- 
lutely no  reason  to  suspect  but  also  where  it  is  possible  to  quite  exclude 
a  scarlatinous  origin.  Some  of  these  cases  have  followed  soon  after  a 
definite  "  chill "  or  exposure,  others  were  in  appearance  idiopathic,  and  in 
still  others  there  was  suspicion  or  evidence  of  pre-existent  chronic  neph- 
ritis. On  the  whole  I  am  of  opinion  that  apparently  idiopathic  nephritis, 
including  nephritis  from  "  chill,"  is  much  more  common  in  children  than 
in  adults.  As  regards  severity  and  complications  I  know  of  no  absolute 
difference  between  scarlatinous  and  other  nephritis.  In  one  of  my  cases 
with  well-marked  dropsy  and  nephritic  urine  of  certainly  non-scarlatinous 
origin  there  were  pneumonia  and  slight  pericarditis  followed  by  recovery. 

The  prognosis  of  acute  nephritis  in  children  is  on  the  whole  good,  the 
large  majority  of  scarlatinous  and  apparently  idiopathic  cases  recover- 
ing with  seeming  completeness.  Nevertheless  recurrence,  after  complete 
disappearance  of  nephritic  symptoms,  with  slight  or  indiscoverable  ex- 
citing causes  is  probably  not  very  rare,  several  instances  having  come 
under  my  notice ;  and  the  question  may  be  asked  though  not  definitely 
answered  whether  these  are  not  really  cases  of  chronic  nephritis  of 
almost  stationary  character  or  very  slow  progress.  Chronic  nephritis 
with  its  usual  symptoms  is  however  not  a  common  sequela  of  the  acute 
form  in  young  children,  but  is  seen  more  often  in  later  years. 

Of  chronic  nephritis  of  insidious  origin  it  need  only  be  said  that  it  is 
of  uncommon  occurrence  in  childhood  and  has  no  special  characteristics. 
Both  the  large  and  small  forms  of  morbid  kidney  may  occasionally  be 
found.  I  have  notes  of  three  cases  with  dropsy,  scanty  urine,  and 
plenteous  albumen  of  which  I  could  give  no  explanation,  and  of  one 
ending  in  uraemia  and  death  in  which  there  had  long  been  copious 
urine  with  little  albumen  and  no  dropsy.  In  all  instances  of  chronic 
albuminuria  the  possibility  of  lardaceous  disease  should  be  remembered. 
Such  cases  are  liable  to  attacks  of  acute  nephritis,  as  was  shown  in  a  girl, 
aged  7,  who  had  three  years  previously  suffered  from  hip  disease  which 


ANASARCA  AND  KIDNEY  DISEASE.  I  I  I 

had  apparently  been  cured.  She  was  attacked  suddenly  with  hematuria, 
oliguria  and  dropsy  and  died  after  a  month's  illness.  Lardaceous  change 
was  marked  in  kidney,  liver  and  spleen.  "With  respect  to  the  prognosis 
of  individual  cases  of  nephritis,  whether  acute  or  chronic,  there  is  nothing 
special  in  childhood.  In  chronic  cases,  as  in  adults,  dilatation  and  uneasy 
working  of  the  heart  are  of  bad  omen. 

Without  entering  into  any  discussion  regarding  the  possible  existence 
of  a  persistent  albuminuria  without  ill  health  which  is  not  due  to  neph- 
ritis, or  dwelling  at  all  on  the  so-called  "functional"  albuminuria  of 
adolescence,  I  would  here  only  record  my  complete  agreement  with 
Goodhart  and  others  who  have  given  special  attention  to  this  subject 
that  such  conditions  are  at  least  extremely  rare  and  should  as  a  rule 
be  ignored.  Chronic  albuminuria  must  for  safe  practice  be  regarded  and 
treated  as  chronic  nephritis. 

The  proper  treatment  of  acute  nephritis  in  childhood  is  in  no  way 
special.  Besides  carefully  maintaining  warmth  in  bed,  and  ordering 
a  milk  diet  with  no  stint  of  water,  of  which  the  child  may  drink  as 
much  as  he  wants,  we  should  endeavour  to  act  on  the  skin,  when 
symptoms  indicate  it,  by  hot-air  baths  daily  repeated  with  due  regard 
to  their  effects,  or  in  default  of  this,  by  ordinary  hot-water  baths, 
with  avoidance  of  subsequent  chilling.  Many  order  more  or  less  con- 
tinuous wet-packing  instead  of  or  in  addition  to  the  baths.  From 
experience  I  strongly  deprecate  the  use  of  pilocarpin,  especially  with 
children,  but  always  try  to  increase  the  urinary  secretion,  when  it  is 
scanty,  by  the  alkaline  diuretics  or  caffeine.  The  benzoate  of  soda  is 
also  recommended  for  this  purpose  by  Goodhart  and  others.  As  long 
as  there  is  plenty  of  healthy  renal  structure  we  may  often  succeed  in 
thus  increasing  diuresis,  but  all  so-called  diuretics  are  certainly  impotent 
in  proportion  to  the  amount  of  renal  mischief  present.  If  no  effect 
follow  their  administration  the  trial  should  be  abandoned.  Digitalis, 
I  think,  is  only  useful  or  not  unadvisable  in  cases  where  the  heart's 
action  with  undue  frequency  and  irregularity  otherwise  indicates  it. 
With  a  slowly  acting  heart,  in  spite  of  scanty  urine  and  dropsy,  it  should 
not  be  given. 

It  is  probably  on  the  whole  well  to  endeavour  to  promote  daily 
evacuation  of  the  bowels,  but  much  purgation  is  to  be  avoided,  as  never 
diminishing  otherwise  recalcitrant  dropsy  but  often  causing  harmful 
or  even  dangerous  depression  of  the  patient.  Marked  diarrhoea  indeed 
may  occur  in  cases  of  nephritic  oedema,  the  dropsy  remaining  unaltered. 
In  many  cases  only  occasional  aperients  are  advisable. 

I  omit  all  detailed  treatment  of  urgent  symptoms  and  complications, 
as  common  to  the  affection  at  all  ages,  and  as  regards  chronic  nephritis 
I  woidd  only  say  that  in  children  or  in  adults  each  case  shoidd  be 


I  I  2        DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

treated  on  its  own  merits  and  according  to  general  indications,  and 
that  a  continuously  monotonous  and  non- nitrogenous  diet  theoretically 
prescribed  will  often  bring  about  multiform  harm  with  no  corresponding 
advantage. 

Tubercular  disease  of  the  kidneys,  both  in  the  miliary  and  caseous 
or  strumous  forms,  is  common  in  children.  Miliary  tuberculosis,  occur- 
ring usually  as  a  part  of  the  general  disease  and  having  no  special 
symptoms,  can  only  be  approximately  guessed  at.  Often  there  are  no 
clinical  signs  whatever.  The  strumous  form  frequently  affects  only  one 
kidney,  at  least  for  a  long  while,  may  be  unaccompanied  by  any  signs  of 
disease  elsewhere,  and  is  generally  characterized  by  pyuria,  hsematuria 
and,  sometimes,  by  the  presence  of  a  tumour  in  the  renal  region.  It  can 
frequently,  though  not  always,  be  diagnosed  from  calculous  kidney  by 
concomitant  symptoms  and  by  the  fact  of  pyuria  predominating  over 
hsematuria,  the  converse  being  mostly  the  case  in  calculous  mischief. 
In  a  case  of  mine,  however,  which  began  three  years  before  admission 
with  nocturnal  enuresis  soon  followed  by  hsematuria,  the  hsematuria 
ceased  for  two  years,  but  the  enuresis  continued  and  there  was  much 
wasting.  Hsematuria  then  recurred  for  two  months.  On  admission 
there  was  plenteous  urine,  with  no  albumen  but  a  considerable 
quantity  of  mucus ;  the  right  kidney  was  felt  to  be  enlarged,  and 
there  were  some  slight  signs  of  disease  at  the  right  pulmonary  apex. 
Two  ounces  of  thick  pus  were  evacuated  by  Mr.  Parker  from  the 
right  kidney  and  the  very  large  cavity  was  plugged  antiseptically. 
At  the  necropsy  both  kidneys  were  markedly  "  strumous "  and  there 
was  some  slight  caseous  change  at  both  pulmonary  apices.  In  all 
ingravescent  cases,  where  the  diagnosis  is  made  of  strumous  kidney, 
nephrotomy  and  drainage  should  be  practised,  with  instant  or  sub- 
sequent nephrectomy  if  the  disease  prove  to  be  very  extensive  or 
the  symptoms  increase.  In  one  case  of  this  kind  in  a  young  woman, 
where  nephrectomy  was  performed  for  me  at  Westminster  Hospital  by 
Mr.  Stonham,  good  health  and  freedom  from  pain,  which  had  been 
severe  and  prolonged,  has  been  secured  for  at  least  two  years,  although 
continuous  slight  pyuria  gives  evidence  that  the  remaining  kidney,  like 
the  excised  one,  is  tuberculous. 

Of  malignant  growth  involving  the  kidney  I  need  only  mention  round- 
celled  sarcoma  which  is  not  uncommon  in  children  under  three  years 
old  and  may  be  found  at  a  later  age.  It  is  of  rapid  growth  and  usually 
forms  an  enormous  abdominal  tumour  before  death  which  is  rarely  later 
than  a  year  from  the  onset  and  most  often  much  earlier.  Like  tuber- 
cular disease  of  one  kidney  sarcoma  may  be  set  up  by  calculous  or  other 
irritants,  but  more  often  its  origin  is  inexplicable  and  it  may  be  con- 
genital.    Most  of  the  symptoms  besides  wasting  are  due  to  interference 


WORMS.  I  I  3 

with  other  organs  ;  hematuria,  however,  is  frequent  and,  unlike  that  due 
to  renal  calculus,  of  constant  occurrence  in  spite  of  rest,  hut  there  is 
often  no  other  symptom  of  kidney  disease.  In  a  well-marked  case, 
aged  2 1  years,  the  first  complaint  was  right-sided  swelling  and  hard- 
ness of  the  ahdomen,  with  fretfulness  and  occasional  pain  and  vomiting 
three  months  "before  admission.  A  very  large  tumour  was  found  in 
the  right  renal  region,  overlaid  hy  the  colon,  hut  there  was  no  other 
abdominal  abnormality  and  the  child  did  not  look  ill.  She,  however, 
rapidly  "became  worse,  and  the  tumour  grew ;  the  urine  was  loaded  with 
urates  and  had  a  slight  trace  of  albumen,  and  the  liver  increased  in  size. 
(Edema  of  the  legs  followed,  and  with  epistaxis  and  bleeding  from  the 
ears  the  child  died  in  general  convulsions  a  fortnight  after  admission. 
Should  a  case  of  this  kind  be  suspected  or  diagnosed  early  from  signs. of 
progressive  renal  tumour  the  question  of  operation  to  prolong  life  may 
he  entertained,  and  an  exploratory  incision  made.  If  the  diagnosis  he 
confirmed  nephrectomy  should  be  performed. 


CHAPTER  XIV. 

WORMS. 

Of  the  various  parasitic  worms  which  infest  the  human  hody  only  the 
two  more  or  less  common  forms  known  as  the  thread-  and  the  round- 
worm need  for  practical  purposes  be  dwelt  upon.  The  tape-worm  of 
either  variety  is  not  common  in  young  children,  and  hydatid  disease, 
though  met  with  from  time  to  time,  claims  no  clinical  distinction  from 
the  affection  as  seen  in  adults.  Out  of  the  several  subjects  of  tape-worm 
which  I  have  seen  in  young  children  none  presented  any  marked  clinical 
symptoms,  and  some  were  markedly  robust  and  healthy.  I  cannot  there- 
fore agree  with  the  view  that  emaciation  is  more  often  to  be  attributed 
to  tape-worm  in  children  than  in  adults.  Both  are  frequently  known 
to  be  harmlessly  affected  thus  for  yeara  As  regards  treatment  I  have 
found  that  the  oil  of  male-fern  in  a  large  dose,  preceded  hy  very  scanty 
diet  for  a  day  and  a  purge  over  night  and  followed  after  a  few  hours  by 
another  purge,  is  very  often  successful  in  removing  the  head  of  the  worm. 
The  frequent  failures  to  hring  away  the  head  are,  I  believe,  mainly  due 
to  want  of  thoroughness  in  carrying  out  this  well-known  method. 

Concerning  the  clinical  import  of  the  presence  of  round-worms  in  the 
body  my  experience  teaches  me  that  they  are  often  expelled  from  the 
anus,  and  sometimes  from  the  stomach  hy  vomiting,  with  no  previous 

H 


I  1 4       DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

symptoms  or  signs  of  ill  health,  and  that  alimentary  disorder  is  no  neces- 
sary condition  of  their  existence.  The  nervous  symptoms  which  have 
been  attributed  to  worms,  such  as  strabismus,  convulsions,  chorea,  night- 
terrors,  cough,  headache  and  the  like,  have  but  slight,  if  any,  claim  to 
consideration  in  this  connexion,  and  markedly  nervous  and  rickety 
children  may  frequently  void  round-worms  with  no  concurrent  nervous 
display.  Abdominal  pain  and  nausea,  however,  may  undoubtedly  pre- 
cede the  vomiting  of  round-worms  which  have  found  their  way  from 
their  habitat  in  the  small  intestine  into  the  stomach,  and  in  such  cases  I 
have  occasionally  observed  convulsions  which,  from  their  isolated  occur- 
rence in  this  association,  may  probably  be  regarded  as  due  to  irritation 
caused  by  the  worms.  Diarrhoea,  moreover,  seems  sometimes  to  be  set 
up  by  the  presence  of  this  parasite,  ceasing  with  its  expulsion.  Among 
the  rarer  symptoms  are  sudden  dyspnoea,  due  to  migration  of  a  round 
worm  into  the  larynx,  jaundice,  from  a  similar  occupation  of  the  common 
bile-duct,  and,  perhaps,  obstruction  of  the  bowel  from  great  masses 
formed  by  very  numerous  worms  which  are  occasionally  present.  A 
practical  point  to  remember  is  that  children  who  eventually  drift  into 
tubercular  peritonitis  are  often  treated  in  an  earlier  stage  for  round- 
worms. In  such  cases,  where  worms  happen  to  be  passed,  the  true  cause 
of  the  symptoms  is  likely  to  be  ignored.  Mr.  Scott  Battams  has  seen 
several  instances  in  point,  and  informs  me  of  one  child  he  saw  suffering 
from  attacks  of  vague  abdominal  symptoms  who  had  previously  been 
treated  with  worm-medicines  followed  by  the  expulsion  of  many  lum- 
brici.  The  symptoms  were  said  to  be  similar  to  those  of  the  first  attack, 
but  the  case  proved  to  be  tubercular  peritonitis. 

It  is  not  to  be  denied,  in  spite  of  what  has  been  said,  that  many 
children  who  pass  round- worms  are  the  subjects  of  alimentary  disorder, 
and  that  it  is  probable  that  an  unhealthy  condition  of  the  intestinal 
mucosa  favours  the  life  and  multiplication  of  these  parasites.  When 
therefore  the  presence  of  round-worms  in  the  intestines  is  suspected  or 
proved,  careful  attention  to  diet  and  to  the  state  of  the  alimentary  canal 
is  advisable ;  and  we  should  always  remember  that  round- worms  are  more 
often  multiple  than  single.  The  best  medicinal  treatment  consists  in 
giving  santonine  with  a  little  calomel  for  three  or  four  nights  in  succes- 
sion, followed  by  a  morning  dose  of  castor-oil.  Oil  of  turpentine  with 
castor-oil  is  also  useful  and  may  be  given  when  santonine  is  not  well 
borne.     In  all  cases  plenty  of  salt  should  be  taken  with  meals. 

Thread-worms  infest  the  large  bowel,  especially  inhabiting  the  caecum 
according  to  some  authorities;  but  they  are  usually  numerous  in  the 
rectum  and  may  often  be  seen  moving  about  the  anus  and  vulva.  Their 
chief  and  most  troublesome  symptom  is  itching  in  these  localities,  which 
at  night  is  generally  excessive.     Often  there  is  evidence  of  concomitant 


DIAGNOSIS  OF  ABDOMINAL  DISEASK.  I  I  5 

catarrh  of  the  lower  bowel,  such  as  abundant  and  often  sanious  mucus, 
loose  motions  and  tenesmus,  variously  regarded  as  cause  or  effect  of  the 
presence  of  the  parasites.  Children  who  have  abundant  thread-worms 
often  suffer  from  incontinence  of  urine,  and  some  are  said  to  find 
difficulty  in  emptying  the  bladder  and  to  retain  their  urine  for  several 
hours. 

It  may  be  admitted,  as  in  the  case  of  round- worms,  that  in  a  large, 
number  of  instances  considerable  alimentary  disorder  accompanies  and 
precedes  the  local  effects  and  detection  of  thread-worms,  and  that  pro- 
bably such  a  condition  is  greatly  contributory,  if  not  necessary,  to  their 
extensive  propagation.  I  have  nevertheless  seen  a  number  of  cases, 
which  were  brought  on  account  of  the  local  trouble  alone,  where  thread- 
worms were  abundant  and  the  general  health  and  state  of  nutrition 
thoroughly  good.  On  the  other  hand  among  the  very  many  cases 
brought  with  the  maternal  diagnosis  of  "  worms,"  based  on  the  popularly- 
believed  symptoms  of  ravenous  appetite  and  nose-picking,  I  have  almost 
always  failed  to  obtain  evidence  of  the  existence  of  either  thread-worms 
or  round-worms  even  after  repeated  doses  of  vermicide  and  purgative 
medicines.  It  is  probable  that  whenever  thread-worms  exist  in  any 
quantity  local  irritation  is  always  complained  of. 

I  have  found  nothing  better  for  the  treatment  of  thread-worms  than 
copious  and  high  injections  of  salt  and  water  in  the  proportion  of  half 
an  ounce  to  a  pint,  coupled  with  saline  or  aloetic  purgatives.  The  local 
irritation  is  remedied  by  mercurial  ointments  which  at  the  same  time 
serve  to  kill  some  of  the  parasites.  "Whenever  there  is  any  indication 
of  gastro-intestinal  disorder  appropriate  treatment,  both  as  to  diet  and 
medicines,  should  of  course  be  instituted. 

Concluding  Eemaeks  conceening  the  Diagnosis  of 
Abdominal  Disease. 

There  is  doubtless  a  certain  fades  which  suggests  painful  abdominal 
disease,  characterized,  as  has  often  been  pointed  out,  by  more  or  less  deep 
lines  extending  from  the  alee  nasi  to  the  corners  of  the  mouth,  by  some 
dilatation  of  the  nostrils,  and  by  a  generally  distressful  expression.  An 
exaggerated  form  of  such  expression  is  seen,  as  it  were  diagrammatically, 
in  any  case  of  severe  colic.  Grave  and  chronic  abdominal  mischief  may, 
however,  occur  without  these  distinguishing  marks. 

Enlargement  of  the  abdomen  is  of  various  import.  It  is  often  tem- 
porarily marked  in  babies,  and  due  then  to  distension  of  stomach  or 
intestine  with  gas  from  imperfect  digestion  or  sometimes  from  swall ow- 
ing air.  The  diagnosis  of  this  condition  rests  on  the  absence  of  marked 
tenderness  and  of  other  abnormal  signs  on  percussion.     Eickety  children 


1 1 6        DISORDERS  OF  ALIMENTARY  TRACT  AND  ABDOMEN. 

have  frequently  large  abdomens  from  flatulent  distension,  flabby  muscles 
and  thoracic  deformity,  and  this  sign  is  often  seen  in  chronic  diarrhoea 
so  often  popularly  diagnosed  as  "  consumptive  bowels."  In  some  cases 
persevering  deep  palpation  will  detect  the  glandular  masses  of  various 
size  which  point  to  tuberculosis.  In  older  children  there  occur  from 
time  to  time  cases  of  extreme  distension,  most  marked  in  the  epigastrium, 
which  are  due  to  dilatation  of  the  stomach,  as  described  by  Henoch.  I 
have  seen  a  few  instances  both  in  boys  and  girls.  This  condition  may 
be  temporarily  relieved  or  soon  disappear  entirely,  but  may  persist  for 
long.  It  is  undoubtedly  of  the  nature  of  hysterical  maladies,  and  is 
possibly  connected  with  spasm  of  the  gastric  orifices.  Enlargement 
with  marked  pain  and  tenderness  suggests  peritonitis  or  a  latish  stage 
of  bowel  obstruction.  Although  intussusception  is  not  usually  thus 
characterized  at  the  outset  I  have  seen  more  than  one  case  where  sudden 
enlargement  with  tenderness  was  the  first  observed  symptom.  In  enteric 
fever,  even  without  peritonitis,  there  is  sometimes  very  notable  abdominal 
enlargement.  Enlargement  with  localised  or  general  dulness  points  to 
disease  of  one  or  more  of  the  abdominal  organs,  especially  of  the  liver, 
spleen,  kidney  or  the  retro-peritoneal  or  mesenteric  glands ;  to  inflam- 
matory or  other  growths  of  the  peritoneum  or  of  the  pelvic  organs ;  or 
to  effusion  of  fluid.  Sarcomatous  disease  of  the  abdomen,  especially  in 
the  omentum,  forms  large  and  hard  growths,  and  very  distinct  and  con- 
siderable tumours  may  be  formed  by  fsecal  accumulations  which  are 
sometimes  so  hard  as  not  to  be  indented  by  pressure. 

Flattening  of  the  abdomen  may  be  seen  in  some  cases  of  simple 
atrophy,  and  occasionally  in  peritonitis  with  extensive  adhesions ;  but 
when  much  marked  in  any  but  very  chronic  cases  of  wasting  it  is  often 
indicative  of  cerebral  disorder,  and  especially  of  tubercular  meningitis 
in  association  with  constipation. 

Want  of  normal  movement  of  the  abdominal  walls  during  respiration 
should  be  noted  as  suggesting  peritonitis  or  paralysis  of  the  diaphragm. 

In  palpating  the  abdomen  the  flat  of  the  hand,  which  must  not  be 
cold,  should  be  used  at  first,  and  the  enlargement  of  any  organ  or  a 
morbid  growth  must  be  defined  by  the  fingers  with  as  little  force  and 
movement  as  possible.  Prodding  the  abdomen  with  the  points  of 
the  fingers  is  useless  for  defining  the  spleen,  liver,  enlarged  glands  or 
growths,  and  causes  the  child  to  hold  its  breath  after  full  inspiration 
or  to  cry.  The  time  when  the  child  is  quietest,  be  it  early  or  late  in 
the  examination,  should  be  seized  for  manipulating  the  abdomen,  for 
restlessness  and  screaming  interfere  more  with  this  than  with  auscultation 
or  even  percussion  of  the  chest. 


SECTION    II. 

GENERAL   DISEASES. 


SECTION  II.— GENERAL  DISEASES. 

Under  this  somewhat  vague  heading  I  shall  treat  of  a  heterogeneous 
group  of  diseases  which  have  the  common  marks  of  profoundly  affected 
nutrition  and,  for  the  most  part,  of  more  or  less  chronicity.  It  is  not 
possible,  nor  would  it  he  useful  from  the  clinical  point  of  view,  to  make 
any  rigid  classification  on  serological  grounds  of  the  affections  to  be 
considered  here,  or  to  separate  them  strictly  from  the  group  of  general 
febrile  disorders  described  in  the  subsequent  section.  In  each  of  these 
groups,  which  are  characterized  by  generality  of  symptoms,  there  are 
instances  of  both  specificity  of  origin  and  of  febrility,  and  in  each  are 
found  examples  of  what  is  commonly  known  as  "  constitutional "  disease, 
a  term  in  my  opinion  too  equivocal  to  be  maintained.  For  clinical 
purposes  alone  the  following  subjects  are  grouped  together. 


CHAPTER    I. 

RICKETS. 

Familiar  and  for  the  most  part  easily  recognised  as  this  disease  is,  it 
nevertheless  hardly  lends  itself  to  accurate  definition.  The  multiform 
conditions  out  of  which  rickets  seems  to  arise  and  the  complex  character 
of  its  morbid  processes,  which  cannot  be  arranged  in  strict  pathogenic 
order,  forbid  us  to  dogmatize  concerning  its  essential  nature.  With  a 
practical  end,  therefore,  in  view  we  must  pass  over  several  questions 
of  morbid  anatomy  and  pathology,  confining  ourselves  mainly  to  what 
seem  the  chief  conditions  out  of  which  the  disease  springs  and  to  the 
most  important  points  in  its  symptomatology  and  treatment. 

The  most  salient  marks  of  rickets  are  enlargement  of  the  growing 
ends  and  borders  of  bones,  especially  of  the  ribs  and  linibs,  more  or 
less  sweating,  particularly  of  the  head,  much  muscular  weakness  and 
a  great  liability  to  convulsions  with  or  without  laryngismus.  In  many 
cases,  though  by  no  means  in  all,  there  are  other  signs  of  widespread 
bad  nutrition  with  digestive  disturbance,  and,  although  very  often  all 
traces  of  the  disease  may  disappear,  many  cases  die  directly  or  indirectly 
from   the   affection  itself   or   from  abdominal  or   pulmonary  disorder, 


120  GENERAL  DISEASES. 

and  in  many  others  deformities  and  stunting  of  the  skeleton  persist 
as  results  of  that  affection  of  the  bones  which  may  be  regarded  as 
the  central  fact  in  the  morbid  anatomy,  though  not  in  the  pathogeny, 
of  the  disorder.  So  liable  indeed  are  rickety  children  to  pulmonary  and 
alimentary  affections,  and  so  frequently  fatal,  owing  to  weakness  both 
of  bone  and  muscle,  are  the  effects  of  the  former  upon  them,  that  this 
disease  must  be  regarded  as  the  true  cause  of  death  in  large  numbers 
of  cases  usually  registered  under  these  headings.  It  is  among  rickety 
subjects  that  whooping-cough,  as  one  instance  out  of  many,  is  especially 
grave  in  its  course  and  event. 

The  symptoms  and  signs  of  rickets  are,  generally  speaking,  as  follow, 
but  are  liable  to  much  variation  especially  according  to  their  earlier  or 
later  onset.  I  have  seen  some  well-marked  cases  where  there  could 
scarcely  be  even  question  of  the  affection  described  as  "acute"  or 
"  scurvy-rickets "  which,  beginning  more  or  less  acutely  with  pyrexia, 
head-sweating  and  some  tenderness  of  body,  soon  showed  the  pathog- 
nomonic epiphysial  enlargement  and  ran  an  ordinary  course  to  recovery. 
I  believe  that  such  an  onset  in  its  milder  forms  is  probably  not  seldom 
overlooked,  and  that  the  pyrexia  is  perhaps  symptomatic  of  the  quasi- 
inflammatory  process  of  perverted  bone-formation  which  may  be  excep- 
tionally rapid  in  these  instances.  Sioeating,  especially  about  the  head, 
is  seen  in  nearly  all  cases,  being  often  the  first  observed  symptom ;  and 
digestive  disturbance,  marked  by  vomiting  or  diarrhoea  or  both  and  by  a 
large  belly,  is  very  frequent.  Wasting  plainly  appears  in  most  instances 
while  the  rickety  process  is  active,  but  the  disease  may  attack  apparently 
well-nourished  children,  and  many  retain  their  fat,  though  rarely  or 
never  their  firmness  of  flesh,  throughout  the  course  of  the  affection. 
Convulsion  is  very  often  an  early  symptom  and,  even  when  unattended 
by  other  indications,  its  frequent  recurrence,  especially  after  the  first 
few  months  of  life,  is  mostly  followed  by  demonstrable  rickets.  Too 
much  clinical  stress  can  scarcely  be  laid  on  the  close  association  of  the 
rickety  process  and  the  convulsive  habit.  Laryngismus  is  almost  exclu- 
sively met  with  in  connexion  with  rickets,  and  tetany,  an  expression  of 
the  convulsive  tendency,  is  largely  referable  to  the  same  origin.  Infantile 
convulsions  are  the  result  of  the  very  unstable  equilibrium  of  the  unde- 
veloped and,  at  the  same  time,  rapidly  developing  nerve  centres,  and  this 
condition  is  markedly  enhanced  by  the  imperfect  nutrition  which  is  the 
probable  cause  of  rickets.  Convulsions  may  occur  throughout  the  course 
of  rickets  and  are  not  seldom  coincident  with  death.  Out  of  one  set  of 
33  cases  dying  from  various  causes  with  severe  rickets  in  my  wards 
5  were  convulsively  moribund.  Laryngismus  is  sometimes  immediately 
fatal. 

The  characteristic  osteal  changes  are  of  the  most  prominent  diagnostic 


RICKETS.  I  2  I 

importance,  the  earliest  to  appear  being  the  enlargements  at  the  epiphy- 
sial ends  of  the  long  hones  and  at  the  borders  of  the  skull  bones ;  while 
the  deformities  which  often  result  from  the  bony  softening  during  the 
rickety  process  are  usually  of  later  date  and  mainly  due  to  movement 
and  pressure.  The  earlier  the  disease  sets  in  the  more  marked  are  all 
the  osteal  changes.  Epiphysial  enlargement  is  observed  first  and  almost 
always  at  the  junction  of  the  ribs  with  the  costal  cartilages,  and  more 
markedly  at  the  lower  and  more  movable  ribs,  such  as  the  fifth,  sixth, 
and  seventh,  than  higher  up.  When  marked  this  beaded  condition  of 
the  ribs  is  named  the  "  rickety  rosary."  In  some  cases  there  may  be  no 
other  definite  signs  of  rickets  than  slight  and  almost  invisible  beading 
of  the  ribs,  to  be  detected  with  certainty  on  careful  palpation  only,  and 
a  tendency  to  head-sweating.  From  the  great  softness  of  the  bones  in 
many  cases  the  thorax  is  deformed  by  marked  depressions  outside  the 
rows  of  "beads,"  and  often  by  another,  known  as  Harrison's  sidcus, 
running  transversely  from  about  the  root  of  the  ensiform  cartilage 
towards  the  axilla?  on  either  side.  These  grooves  are  probably  caused 
by  atmospheric  pressure  on  the  morbidly  soft  ribs  and  are  deepened 
with  the  indrawn  breath.  The  lower  part  of  the  breast-bone  is  propor- 
tionately thrust  forward,  often  giving  rise  to  a  special  shape  of  thorax 
the  transverse  section  of  which  in  its  lower  part  has  been  well  likened 
to  the  shape  of  the  body  of  a  fiddle  with  its  shoulders  foremost.  Great 
thoracic  deformity  is  seen  mostly  in  badly  nourished  children  who 
have  suffered  from  pulmonary  affections  that  put  much  stress  on  the 
softened  ribs  already  yielding  to  ordinary  pressure. 

Scarcely  less  frequent  than  the  "  beaded  "  ribs  is  enlargement  at  the 
ends  of  the  limb-bones  especially  at  the  wrists  and  ankles — the  most 
mobile  and  hard-worked  joints  in  infancy — both  before  and  after  the 
child  begins  to  crawl  and  fall  about.  In  marked  cases  this  epiphysial 
enlargement  is  often  called  "  double-jointedness."  The  bony  shafts  of 
the  legs  and  arms  may  become  bent  in  various  directions  and  degrees, 
mainly  from  the  pressure  of  use,  or  of  position  while  the  child  is  carried, 
these  deformities  being  comparatively  seldom  seen  in  the  youngest  sub- 
jects of  the  disease.  The  upper  extremities  are  usually  most  distorted  in 
children  who  crawl,  the  lower  are  very  often  bowed  outwards  in  those  who 
have  walked,  and  other  flexures  may  occur  as  well.  "What  is  known  as 
"  green-stick  fracture "  of  the  clavicles  and  other  bones  is  frequently 
seen  at  this  stage,  the  time  of  its  occurrence  being  unknown.  Com- 
plete fracture  but  very  rarely  takes  place,  and  only,  it  is  generally 
believed,  in  cases  which  date  from  foetal  life.  Bending  of  the  bones 
is  sometimes  the  first  symptom  noted  when  the  onset  of  the  disease  has 
been  either  too  late  or  too  mild  to  prevent  the  child's  walking. 

The  vertebral  column  may  be  bent  backwards  in  the  dorsal  region,  and 


122  GENERAL  DISEASES. 

there  is  frequently  lateral  curvature  as  well ;  such  deformities,  however, 
disappearing  when  the  child  is  lying  prone  or  is  suspended  by  the  arm- 
pits, except  in  cases  where  the  sitting  posture  has  been  long  maintained. 
These  phenomena  are  referable  to  muscular  weakness.  Neglected  rickets 
is  doubtless  a  frequent  cause  of  round  backs  and  drooping  shoulders, 
which  are  often  and  deplorably  maltreated  by  orthopaedic  artifice. 

The  skull  often  shows  marked  signs  of  affection  at  a  very  early  period 
owing  to  the  perverted  bony  growth  presently  to  be  noticed.  "  Bossy  " 
swellings  appear  on  the  bones,  especially  on  the  frontals  and  parietals, 
and  there  are  often  elevations  along  the  sutures.  The  forehead  may 
appear  large  and  square,  the  top  of  the  head  flattened,  and  a  ridge  may 
be  seen  at  each  side  of  the  median  groove.  In  many  cases  the  head  is 
long  and  often  broad  posteriorly,  and  there  is  occasionally  a  prominent 
vertical  ridge  in  the  middle  of  the  forehead.  Sometimes  there  is  marked 
cranial  asymmetry,  or  the  head  may  be  abnormally  large.  Hydrocephalus, 
be  it  remembered,  is  not  seldom  coincident  with  rickets,  and  in  some  cases 
there  is  reason  to  believe  that  the  brain  itself  is  hypertrophied. 

Yielding  areas  of  imperfect  ossification  are  often  felt  close  to  the 
lambdoidal  and  other  sutures,  and  localised  spots  of  thinned  bone  may 
appear  at  a  distance  from  the  sutures  on  the  occipitals  and  parietals 
during  the  first  year.  This  latter  condition  has  been  long  known  as 
"  cranio-tabes "  and  considered  as  a  special  mark  of  rickets.  Leading 
modern  authorities  have  affirmed  or  denied  this  position.  For  myself, 
after  examining  very  numerous  rickety  cases  for  this  phenomenon,  I 
incline  to  agree  with  the  original  opinion  of  Dr.  T.  Barlow  that  cranio- 
tabes  is  but  seldom  seen  in  rickets  where  syphilis  is  not  markedly 
present,  and  hardly  ever  where  it  can  be  with  any  great  probability 
excluded;  and  I  am  convinced  that  many  reported  cases  of  rickety 
cranio-tabes  are  referable  to  the  imperfect  ossification  in  the  neighbour- 
hood of  the  sutures  which  I  have  mentioned  above.  Further,  a  condi- 
tion closely  allied  to  this,  though  less  well  localised,  is  to  be  found  in 
badly  nourished  children  with  thin  skulls,  apart  from  any  evidence  of 
other  disease. 

The  sutures  are  generally  late  in  ossifying,  and  the  anterior  fontanelle, 
closed  as  a  rule  in  health  at  the  age  of  i  J  years,  may  be  open  until  the 
fourth  year  or  later.  The  lower  jaw,  as  justly  described  by  Fleischmann, 
is  sometimes  much  altered  in  shape,  losing  its  curve  and  turning  sharply 
backwards  beyond  the  lateral  incisors.  The  teeth  are  of  late  and 
irregular  eruption,  and  soon  decay.  It  must  be  remembered  that  both 
the  cranial  and  dental  abnormalities  are  most  prominent  in  early  rickets, 
and  that  in  cases  where  the  disease  is  delayed  till  the  18th  month  or 
later  they  may  be  altogether  absent.  At  whatever  period,  however, 
rickets  begins,  dentition  and  ossification  are  arrested  or  modified. 


RICKETS.  1 2  3 

I  would  add  here  that,  in  spite  of  all  clinical  and  anatomical  research, 
it  is  an  almost  insuperable  practical  difficulty  to  the  physician  in  some 
cases  to  differentiate  between  rickety  and  syphilitic  bony  overgrowth, 
whether  it  be  at  the  epiphyses  or  elsewhere,  and  we  must  ever  bear  in 
mind  that  rickets  attacks  considerable  numbers  of  syphilitic  children. 

Restlessness  and  irritability  are  often  present,  the  child  frequently 
throwing  off  the  bedclothes  and  lying  completely  doubled  up,  head 
foremost.  My  experience  bears  out  the  old  teaching  that  tenderness  of 
the  body  and  especially  of  the  limbs  on  movement  or  pressure  is  a  very 
significant  symptom.  Excessive  tenderness,  however,  according  to  many 
authorities,  is  confined  to  a  class  of  cases  presently  to  be  noticed,  which 
is  variously  described  as  "  acute  rickets  "  or  "  infantile  scurvy." 

Rickets  is  so  often  associated  or  complicated  with  profound  digestive 
disturbance  and  pulmonary  affection,  and  is  so  indefinitely  prolonged  by 
the  continuance  of  its  causal  conditions,  that  there  is  little  of  practical 
value  to  say  concerning  its  duration.  Of  the  above-mentioned  33  deaths 
20  were  due  to  bronchitis  and  broncho-pneumonia,  2  to  general  tuber- 
culosis with  meningitis  and  6  to  gastro-intestinal  disorder  with  profound 
atrophy.  There  was  positive  evidence  of  congenital  syphilis  in  14  out 
of  100  in-patient  cases  which  I  have  recently  tabulated,  and  a  previous 
syphilitic  history  in  10  others.  I  would  remark  here,  however,  with 
reference  to  the  once  burning  but  now  extinct  question  of  the  exclusively 
syphilitic  causation  of  rickets,  that  in  a  majority  of  these  100  cases  there 
is  recorded  an  absence  of  all  evidence  of  syphilis,  and  can  state  more- 
over, from  a  prolonged  experience  of  both  in-  and  out-patient  children  in 
a  district  of  London  where  both  syphilis  and  rickets  are  truly  endemic, 
that,  while  very  large  numbers  of  markedly  syphilitic  children  which 
survive  for  six  months  become  rickety,  a  very  great  proportion  of  rickety 
infants  are  free  from  all  past  or  present  evidence  of  syphilis.  I  have 
further,  outside  hospital  practice,  seen  rickets  develop  several  times 
where  syphilis  could  be  positively  excluded. 

In  cases  which  do  not  succumb  to  some  of  the  many  accidents  of  the 
disease  there  is  a  marked  tendency,  with  the  suspension  of  the  causal 
conditions,  for  the  essential  symptoms  to  diminish  gradually  or  disappear. 
In  many  instances,  both  slight  and  otherwise,  the  epiphysial  enlargement 
may  be  altogether  obscured  in  the  process  of  healthy  growth,  and  the 
crooked  limbs  become  straight  with  a  frequency  surprising  to  the  in- 
experienced. Even  in  the  severer  cases,  without  complications,  early 
treatment  will  often  give  pause  to  the  activity  of  the  disease,  leaving 
the  resulting  deformities  alone  to  signify  its  occurrence.  Sometimes, 
and  especially  when  neglected,  the  symptoms  of  the  affection  are  con- 
tinuous or  recurrent  till  the  fourth  year  or  later.  Of  the  permanent 
results    of   rickets   there    are   abundant   examples   in  stunted  growth, 


124  GENERAL  DISEASES. 

deformed  limbs,  distorted  pelves  and  mis-shapen  heads.  Thoracic  defor- 
mities in  adults  are  not  very  numerous,  owing  to  the  prevalent  and  early- 
fatality  of  cases  thus  characterized.  The  most  typical  rickety  form  of 
pigeon-breast  is  not  often  seen  after  early  childhood. 

Enlargement  of  the  liver  and  spleen  is  frequently  dwelt  on  as  part  of 
the  indications  of  rickets,  but  my  experience  does  not  permit  me  to  adopt 
this  teaching.  As  regards  clinical  evidence  of  this,  a  large  majority  of 
my  cases  are  noted  as  normal  in  these  respects.  In  9  out  of  the  100 
above  mentioned  both  organs  were  palpably  enlarged,  but  not  exces- 
sively ;  in  5  the  liver  alone ;  and  in  1  the  spleen  alone.  In  early  rickets, 
however,  Avith  active  symptoms  and  much  wasting  the  liver  is  very  often 
enlarged.  With  regard  to  marked  enlargement  of  the  spleen  I  am  quite 
in  accord  with  Henoch  who,  with  an  enormous  experience,  regards  this 
phenomenon  as  only  fortuitously  connected  with  rickets.  Such  enlarge- 
ment is  frequent  enough  with  profound  anaemia  without  leucocytheemia, 
as  my  own  experience  abundantly  testifies,  and  is  certainly  very  often 
connected  with  syphilis.  Enlarged  spleens  and  livers  in  rickety  cases 
examined  post-mortem  show  nothing  really  distinctive  either  macro- 
scopically  or  microscopically. 

The  morbid  anatomy  of  rickets  is  a  subject  of  great  extent  and  diffi- 
culty, and  I  can  but  touch  on  it  in  the  most  general  terms.  As  the  most 
prominent  symptoms  of  the  disease  are  those  of  the  bone-affection,  so 
the  only  approximately  pathognomonic  changes  found  post-mortem  are 
confined  to  the  bones  and  bone-forming  tissues.  The  exact  nature  and 
starting-point  of  the  process  is  not  agreed  upon,  and  I  must  content 
myself  with  quoting,  with  one  addition,  the  words  of  Dr.  Barlow  that  it 
is  "an  irritating  overgrowth  of  the  osteogenetic  tissues,  and  that  this 
and  not  the  deprivation  of  lime  is  the  primary  (anatomical)  fact  in 
the  disease."  There  is  great  vascularity  and  swelling  both  at  the  carti- 
laginous and  periosteal  seats  of  the  change,  formation  of  spongy  though 
chemically  normal  bone,  absorption  of  normal  bone,  or  the  deposition  of 
soft  bone  containing  little  or  no  lime. 

In  some  cases  there  is  swelling  of  the  connective  tissue  around  the 
bones  and  among  the  neighbouring  ligaments  and  muscles,  which  con- 
tributes to  muscular  and  articular  weakness.  The  resulting  deformities 
depend  on  the  predominance  of  one  or  other  of  the  above  changes,  the 
epiphysial  enlargement  being  due  mainly  to  the  cartilaginous  swelling, 
while  the  skeletal  deformities  are  largely  referable  to  destructive  changes 
or  deficient  formation  of  the  bones.  In  many  cases  of  advanced  rickets 
the  proportion  of  lime  salts  is  very  much  diminished,  but  this  condition 
is  said  to  be  by  no  means  so  general  as  was  formerly  believed.  The 
morbid  process  in  the  bone-forming  tissues  may  be  hypothetical^  attri- 
buted to  irritation  induced  by  the  results  of  that  perverted  nutrition  to 


RICKETS.  I  2  5 

which  I  shall  presently  refer,  and  may  perhaps  be  regarded  as  causing 
in  its  turn  the  complex  of  symptoms  which  is  clinically  known  as  rickets. 
We  are  at  present,  however,  ignorant  of  what  factors  of  faulty  nutrition 
form  the  connecting  links  with  the  hone-affection.  We  must  look  for 
serological  material,  in  default  of  sufficient  demonstration,  to  the  pecu- 
liarities of  the  subjects  of  the  disease  and  to  the  conditions  in  which  it 
seems  to  arise. 

Eickets  makes  its  clinical  appearance  in  a  large  majority  of  cases 
between  the  ages  of  six  months  and  two  years,  but  may  be  occasionally 
observed  at  birth  in  unquestionable  form  quite  apart  from  those  cretinoid 
cases  inaccurately  entitled  "foetal  rickets,"  for  an  account  of  which 
I  must  refer  the  reader  to  the  text-books.  The  age  on  admission  of 
ioo  cases  taken  into  my  wards,  either  in  the  active  stage  or  showing- 
marked  deformities,  varied  from  three  months  to  four  years.  Six  were 
under  six  months,  eleven  between  six  months  and  a  year,  forty-eight 
between  one  and  two  years,  seventeen  between  two  and  three  years 
and  twelve  between  three  and  four  years.  From  the  frequently  insi- 
dious and  gradual  nature  of  the  onset  of  rickets  it  is  not  possible 
to  fix  statistically  the  earliest  date  of  its  appearance,  but,  seeing  that 
microscopical  examination  may  detect  the  special  bone  changes  where 
there  is  little  or  no  clinical  evidence  of  the  disease,  it.  may  be  assumed 
that  it  often  exists  before  its  recognition  is  possible.  I  am  sure,  however, 
as  far  as  most  careful  clinical  inquiry  and,  in  several  instances,  positive 
knowledge  of  infants  observed  from  birth  can  be  taken  as  proof,  that 
rickets  often  sets  in  very  soon  after  weaning-time  in  cases  which,  accord- 
ing to  all  available  evidence,  were  previously  healthy.  I  have  moreover 
known  a  few  children  in  whom  the  disease  apparently  began  after  the 
second  year,  but  I  can  say  nothing  from  personal  experience  of  what 
has  been  described  as  "  late  rickets." 

In  the  East  London  Hospital  practice  at  least,  marked  rickets  is  seen 
nearly  twice  as  often  in  boys  as  in  girls.  This  is  shown  not  only  by 
my  detailed  cases  admitted  as  rickets  but  also  by  a  vastly  larger  number 
of  rickety  in-patients,  registered  in  other  categories,  and  still  more 
numerous  out-patients.  If  this  remarkable  difference  in  the  sexual 
incidence  of  the  disease  be  universal  its  explanation  seems  far  to  seek. 

Eickets  is  rare  in  tropical  climates,  common  in  cold  and  damp  regions, 
comparatively  rare  in  the  country,  and  commonest  of  all  in  the  children 
of  the  poor  in  crowded  towns.  Although  the  existence  of  rickets  in  fat 
children  and  even  in  those  of  otherwise  fairly  healthy  appearance  is  not  to 
be  denied,  I  cannot  but  strongly  dissent  from  those  who  teach  that  obvi- 
ously bad  nutrition  and  pallor  are  absent  in  the  majority  of  cases.  The 
question  of  the  role  of  improper  diet  in  causing  rickets  is  one  of  great 
difficulty.     Certainly  all  special  dietetic  and  chemical  theories  of  causa- 


126  GENERAL  DISEASES. 

tion  have  been  found  erroneous  when  tested  by  close  observation  and 
logical  reasoning ;  and,  although  there  is  good  ground  to  believe  that  a 
diet  defective  in  fat  is  a  very  important  factor  in  many  or  perhaps 
most  cases,  the  prevailing  creed  that  rickets  is  wholly  a  diet  disease 
cannot  be  unreservedly  accepted.  It  is  true  that  any  deviation  from 
sucking  only  at  the  breast  increases  the  chance  of  rickets ;  that  the 
children  of  the  poor,  although  suckled  for  long,  have  usually  the  most 
inappropriate  food  as  well ;  and,  further,  that  improvement  often  follows 
a  discontinuance  of  unsuitable  food.  Yet  it  is  equally  true  that  town 
children  are  far  more  often  rickety  than  country  children,  however  they 
may  be  fed,  and  we  not  infrequently  find  rickety  subjects  who  have 
been  suckled  by  apparently  healthy  mothers  of  the  well-to-do  classes. 
I  can  further  testify  that  even  in  the  East  of  London  there  are  large 
numbers  of  children  who  have  remained  free  from  rickets  in  spite  of 
most  unphysiological  diet.  "We  must  therefore  recognise  other  factors 
of  great  importance  conducive  to  rickets,  and  these  we  shall  find  in  the 
badly-nourished  mother  who  gives  her  infant  the  worst  start  in  life, 
the  deprivation  of  sunlight  and  fresh  air,  the  inhalation  of  air-borne 
poisons  and  all  the  other  evils  of  crowded  and  insanitary  dwellings  ; 
and  we  must  remember  that  it  is  in  these  circumstances  that  most  of  the 
badly-fed  children  are  found.  The  profound  disturbance  of  nutrition, 
moreover,  induced  by  syphilis,  even  when  all  attention  is  paid  to  diet, 
must  be  borne  in  mind  as  a  factor  in  the  production  of  many  cases  of 
rickets. 

"We  must  therefore  at  present  be  content  to  use  the  term  "  perverted 
nutrition  "  to  express  the  earliest  link  in  the  morbid  chain  at  the  end  of 
which  is  rickets,  in  our  ignorance  of  whatever  essential  factor  there  may 
be  in  the  production  of  the  essential  changes  which  mark  the  disease. 
It  may  be  reserved  for  future  study  to  show  that  the  whole  series  of 
nutritive  disturbances  in  rickets  are  due  to  some  original  vice  of  the 
nervous  system,  or  perchance  to  the  operation  of  organic  germs,  but  such 
suggestions  are  at  present  neither  very  luminous  nor  helpful  in  practice. 
This  much  at  least  in  my  opinion  is  certain,  that  among  children  of 
healthy  parentage  who  enjoy  plenty  of  sunlight  and  fresh  air  and  are  in 
generally  good  surroundings  rickets  is  decidedly  rare,  and  that  such 
children  are  not  readily  made  rickety  even  by  inappropriate  methods  of 
feeding.  But,  on  the  other  hand,  I  am  equally  convinced  that  in  the 
large  majority  of  children  who  have  not  these  advantages  bad  feeding 
is  one  of  the  leading  excitants  of  rickets,  and  that  sometimes  the  disease 
arises  without  any  other. 

Of  the  class  of  cases  described  as  acute-  or  scurvy-rieltets  and  now 
generally  referred,  according  to  the  teaching  of  Drs.  Cheadle  and  Barlow, 
to  a  scorbutic  origin  I  shall  say  but  little,  my  own  experience  of  this 


RICKETS.  I  2  7 

affection  being  not  very  extensive.  It  seems  clear,  from  the  literature  of 
the  subject  and  from  several  inquiries  I  have  myself  made  of  practitioners 
abroad,  that  this  complex  of  symptoms,  though  not  of  very  frequent  occur- 
rence, is  much  commoner  in  England  than  elsewhere.  Very  marked 
tenderness  of  limbs,  often  with  apparent  swelling  of  the  bones  and 
especially  of  the  femora,  wasting,  anaemia,  purpura,  and  bleeding  from 
spongy  gums  and  elsewhere  are  the  chief  points  to  be  noticed  in  the 
clinical  picture  of  this  disorder,  which  has  been  fully  described,  from  his 
original  researches,  by  Dr.  Barlow.  The  limb-swelling  has  been  shown 
to  be  due  to  sub-periosteal  haemorrhage  or  extravasations  between  the 
muscles.  Evidence  has  been  brought  to  show  that  in  many  cases  of 
this  affection  there  has  been  a  notable  absence  of  fresh  food  from  the 
diet,  the  infants  being  brought  up  exclusively  on  condensed  milk  and 
on  starchy  or  other  patent  foods.  Several  cases  which  I  have  seen 
myself  were  undoubtedly  rachitic ;  a  few  but  slightly  so,  to  all  appear- 
ance ;  some  had  had  a  diet  much  deficient  in  fresh  milk,  potatoes,  and 
antiscorbutic  material  generally ;  and  one  at  least  had  been  throughout 
fed  in  a  manner  quite  antagonistic  to  the  production  of  scurvy.  In  one 
case  with  advanced  rickets,  which  was  examined  post-mortem,  sub- 
periosteal haemorrhage  was  found,  but  no  other  bleeding  was  evidenced 
either  then  or  during  life.  I  shall  again  allude  to  scorbutus  in  infants, 
which  in  some  degree  is  perhaps  not  very  rare,  and  will  only  say  here 
that  I  think  there  is  reason  to  doubt  the  constantly  scorbutic  causation 
of  sub-periosteal  haemorrhages  occurring  in  connection  with  rickets. 
"What  may  be  called  "acute  rickets"  quite  independent  of  scorbutus, 
without  marked  swelling  but  with  tenderness  of  limbs  and  some  fever, 
has,  as  I  have  already  said,  a  claim  in  my  opinion  to  clinical  recognition. 
Treatment. — Bearing  in  mind  the  view  above  advocated  that  rickets 
is  due  to  defective  nutrition  in  the  widest  sense,  and  may  even  be 
developed  in  intra-uterine  life,  it  is  clear  that  the  prophylaxis  must 
include  the  hygienic  treatment  of  the  mother  as  well  as  of  the  child.  It 
is  unquestionable  that  poverty,  with  its  frequent  accompaniments  of 
repeated  child-bearing  and  prolonged  suckling,  strongly  predisposes  to 
rickets,  seeing  that  the  disease  is  rare  in  the  children  of  those  who  are 
at  once  healthy,  well-to-do  and  well  instructed.  Although  I  cannot 
dwell  here  on  the  matter  of  maternal  hygiene,  and  can  but  refer  the 
reader  to  what  has  been  already  said  on  the  subject  of  the  normal  feeding 
of  infants  and  the  treatment  of  simple  wasting,  I  must  emphasize  the 
contention  that  on  due  attention  to  these  points  depends  the  most 
important  part  of  the  prophylactic  treatment  of  rickets.  Eickets  must 
be  suspected  when  a  child  is  late  in  walking  or  cutting  its  teeth  and  has 
an  unduly  open  fontanelle,  and  in  all  convulsive  or  "croupy"  babies; 
and  such  children,  as  well  as  those  with  more  pronounced  symptoms, 


128  GENERAL  DISEASES. 

must  be  placed  in  conditions  excluding  as  far  as  possible  all  tbe  hygi- 
enic and  dietetic  errors  which  we  regard  as  conducive  to  the  malady. 

For  the  rest,  the  patient  must  be  kept  lying  down  as  much  as  possible, 
and  not  allowed  to  walk  or  crawl  until  there  is  reason  to  believe  that  the 
disease  is  arrested.  Every  opportunity  must,  however,  be  seized  for 
supplying  the  child  with  fresh  air  and  sunlight.  Scrupulous  cleanliness 
should  be  observed,  for  there  is  generally  much  sweating,  and  frequent 
tepid  baths  are  to  be  given.  A  bandage  round  the  abdomen  in  cases 
where  the  thorax  is  affected  is  often  useful,  and  when  there  is  much 
restlessness  with  head-sweating  the  advice  of  Dr.  Charles  West,  that  the 
child  should  be  provided  with  a  horse-hair  pillow  with  a  central  hole, 
may  be  followed  with  much  benefit.  In  most  cases  I  give,  and  I  believe 
with  much  advantage,  cod-liver  oil;  and  iron  preparations  as  well  as 
arsenic  are  of  considerable  use.  Especial  stress  must  be  laid  on  the 
paramount  importance  of  protecting  a  rickety  child,  as  far  as  may  be, 
from  all  sources  of  catching  cold  and  from  all  conditions,  infectious  or 
otherwise,  out  of  which  pulmonary  affections  may  be  suspected  to  arise, 
and  on  the  extreme  care  that  is  necessary  in  the  conduct  of  such  cases 
as  may  be  attacked  by  bronchitis  or  broncho-pneumonia.  It  is  in  rickety 
children  pre-eminently  that  bronchitis  passes  on  to  broncho-pneumonia, 
and  that  fatal  collapse  of  lung  takes  place  owing  to  the  feeble  inspiratory 
power  which  is  due  to  softened  ribs,  weakened  muscles  and  generally 
impaired  nutrition.  I  deprecate  strongly  the  employment  of  rigid 
mechanical  appliances  to  any  part  of  the  body  of  the  rickety  child, 
with  the  exception  of  well-padded  splints  projecting  below  the  feet  to 
prevent  walking  in  cases  where  constant  watching  is  out  of  the  question ; 
and  I  postpone  all  surgical  interference  with  permanently  distorted  limbs 
until  the  disease  is  no  longer  active  and  the  child  has  attained  to  some 
degree  of  vigour.  From  the  artificial  sequelae  of  ill-developed  limbs, 
impeded  bodily  activity  and  impaired  health,  which  sometimes  supervene 
among  the  moneyed  classes  on  the  unnecessary  use  of  mechanical  appli- 
ances, the  children  of  the  poor  are  as  a  rule,  with  a  sort  of  poetical 
justice,  fortunately  exempt. 


SYPHILIS.  1 29 


CHAPTER    II. 

SYPHILIS. 

Although  syphilis  may  infect  children  after  birth  by  inoculation  from 
primary  or  secondary  sores,  I  shall  treat  here  only  of  that  form  which 
is  generally  known  as  "  congenital "  and  is  of  ante-natal  date.     Omit- 
ting discussion  of  the  modes  of  syphilitic  inheritance   I  shall  simply 
state  my  present  views  on  the  matter,  which  are  the  outcome  of  the 
study  of  authorities  and  of  experience  at  a  hospital  where  there  is  no 
minimum  limit  of  age  for  admission.     Apart  from  the  large  numbers 
of   out-patients  that   I   have  seen,   nearly   200   cases    of    unmistakable 
syphilis   appear   in   my  in-patient   case-books,   besides   very  numerous 
instances  of  children,  admitted  for  other  affections,  in  whom  there  was 
either  present  evidence  or  past  history  of  this  disease.     In  many  of 
these  a  fairly  definite  family  history  was  obtained.     The  worst  cases 
are    those    where   both   parents    are    syphilitic,  and   both   gravity   and 
fatality  are  generally  in  proportion  to  the  activity  and  recent  date  of 
the  parental  affection.     That  maternal  syphilis  alone,  especially  when 
active,  is  a  fertile  cause  of  the  infantile  disease  seems  as  certain  as  it 
is  difficult  to  prove  by  mere  inquiry ;  but  I  am  sure  that  whether  or 
no  the  mothers  of  infected  infants  are  themselves  syphilitic  by  foetal 
contamination  or  otherwise,  and  whether  or  no  they  are,  as  is  usually 
taught,  incapable  of  infection  from  their  sucklings,  they  are  in  a  very 
large  number  of  instances,  both  during  pregnancy  and  for  an  indefinite 
after-time,  perfectly  free  from  all  symptoms  of  the  disease.     Both  hos- 
pital and  other  cases  give  ample  evidence  of  this  very  frequent  maternal 
immunity  from  all  apparent  symptoms,  while,  both  from  personal  inter- 
views with  the  fathers  and  from  frequent  though  unwitting  accounts 
given  by  the  mothers  in  answer  to  my  inquiries,  I  have  been  able  to 
establish  a  clear  evidence  of  paternal  syphilis  in  very  many  of  the  cases 
alluded  to.     As  a  matter  of  practice,  seeing  that  congenital  syphilis  is 
eminently  contagious,  and  not  being  quite   convinced  of  the  received 
doctrine  of  maternal  protection,  I  advise  an  apparently  healthy  mother 
not  to  suckle  her  syphilitic  child,  and  positively  refuse  to  sanction  the 
substitution  of  a  wet-nurse  whether  the  child  has  visible  oral  mischief 
or  not.     Further,  without  deciding  on  the  possible  infectiveness  of  the 
milk  of  a  syphilitic  woman,  I  would  not  allow  an  apparently  healthy 
infant  to  be  suckled  by  any  one  affected  with  even  a  suspicion  of 
syphilis. 

I 


130  GENERAL  DISEASES. 

Syphilis  very  frequently  causes  abortion,  and  repeated  abortions  of 
macerated  foetuses  are  practically  always  syphilitic.  Still-birth,  at  or 
about  term,  often  takes  place,  the  infant  being  wasted,  the  skin  dull, 
dry,  inelastic,  and  extensively  discoloured  or  desquamating,  and  some- 
times there  are  bulla?  on  the  palms  and  soles.  Lastly  there  is  a  large 
class  of  cases,  born  alive,  more  or  less  affected  or  soon  to  be  affected 
with  some  of  those  signs  of  syphilis  presently  to  be  noted,  among  which 
obstinate  wasting  is  pre-eminent  and  very  often  of  fatal  import. 

The  more  extensive  the  skin-affection,  eruptive  or  not,  the  worse  is 
the  prognosis.  I  have  seen  many  cases  marked  at  birth  with  an  almost 
universal  scaly  red  rash,  or  less  often  with  a  bullous  eruption  most  pro- 
minent on  the  extremities,  among  other  signs  of  syphilis.  These  babies 
are  small,  old-looking,  and  monkey-like,  and  nearly  always  die  within  a 
few  days  or,  at  most,  weeks  of  birth  in  spite  of  the  best  care  and  most 
orthodox  medication.  They  usually  lie  perfectly  still,  occasionally  utter- 
ing the  feeblest  whine,  and  all  vital  signs  are  often  so  slight  as  to 
obscure  the  moment  of  death.  Some  die  with  the  symptoms  and  post- 
mortem evidence  of  sudden  and  extensive  collapse  of  lung,  and  others 
with  acute  pulmonary  affections.  From  this  class  are  furnished  most 
of  the  specimens  of  visceral  syphilis  and  also  of  the  now  well-known 
bone-affections  which  many  believe  to  be  equally  characteristic  of  the 
disease. 

While  life  lasts  these  infants,  as  well  as  others  who  with  less  marked 
skin-disease  may  live  for  a  longer  period,  often  feed  with  apparent 
voracity,  and  may  be  affected  neither  by  vomiting  nor  diarrhoea.  The 
fasces  in  such  cases,  where  assimilation  of  food  is  at  a  standstill,  are 
usually  copious  and  pasty  or  lumpy,  changes  of  diet  and  drugs  are  alike 
vain,  the  alimentary  canal  seems  little  other  than  an  inorganic  tube,  and 
for  a  while,  except  by  intervals  of  sucking,  life  may  be  evidenced  alone 
by  the  feeble  pulse  and  almost  imperceptible  breathing.  In  several  of 
these  cases  I  have  seen  post-mortem  no  macroscopical  evidence  of 
visceral  disease,  but  only  more  or  less  atrophy  of  the  stomach  and  bowels 
and  general  dryness  of  the  mucosa. 

Various  grades  of  this  syphilitic  malnutrition  may  exist,  and  are 
usually  in  proportion  to  the  early  appearance  of  specific  manifestations. 
I  have  often  thought  that  many  infants  of  apparently  healthy  parentage 
which  are  merely  wasted  from  birth,  and  are  either  largely  or  wholly  irre- 
sponsive to  dietetic  treatment,  are  really  syphilitic  ;  and  this  suspicion  has 
been  frequently  justified  or  rendered  very  probable  by  the  subsequent 
appearance  in  such  cases  of  specific  lesions,  or  by  the  confession  of 
parental  syphilis.  In  some  instances,  doubtless,  this  malnutrition  is 
largely  contributed  to  by  the  many  evils  incident  on  poverty,  and  then 
may  soon  recede  with  proper  treatment,  even  without  specific  medication. 


SYPHILIS.  I  3  I 

Slight  cases  of  wasting,  indeed,  even  when  attended  hy  unquestionably 
syphilitic  lesions,  often  recover  well  and  quickly  under  general  hygienic 
and  nutritive  care  alone. 

Of  the  numerous  syphilitic  infants  which  show  no  definite  signs  of  the 
disease  at  birth  many  are  apparently  healthy,  while  others  are  puny  with 
discoloured  and  inelastic  skin.  Within  the  first,  not  very  often  later 
than  the  second,  and  rarely  later  than  the  third  month,  special  symp- 
toms and  signs  arise.  There  is  wakefulness  at  night,  often  with 
apparent  pain  probably  referable  to  the  bones,  and  nasal  snuffling 
with  visible  discharge.  This  last  symptom  is  almost  invariably  present 
and  is,  further,  strongly  indicative,  though  scarcely  quite  pathognomonic, 
of  syphilis.  Simple  nasal  catarrh  without  cough  is  very  rare  at  this  age, 
and  diphtheritic  coryza,  from  its  rapid  increase  and  concomitant  symp- 
toms, seldom  causes  diagnostic  difficulty.  The  breathing  is  noisy  and 
the  nasal  mucosa  swells  and  often  ulcerates  so  that  the  discharge,  at 
first  glairy,  becomes  sero-purulent  or  bloody,  and  crusts  form  which  may 
cause  the  child  to  stop  sucking  in  order  to  breathe.  The  upper  lip 
is  often  much  excoriated  by  the  nasal  discharge,  and  in  some  cases  there 
are  said  to  be  mucous  patches  or  "condylomata"  on  the  nasal  mem- 
brane. The  ulceration  may  spread  to  the  bone,  leading  to  necrosis.  The 
depression,  however,  at  the  root  of  the  nose,  so  frequent  in  syphilitic 
infants  and  often  observable  in  later  life,  is  not  necessarily  due  to  this 
cause,  for  it  may  occur  when  the  snuffles  have  been  slight.  The  cry  is 
often  hoarse,  feeble,  or  silent  from  varying  degrees  of  laryngeal  involve- 
ment. Most  cases  are  marked  by  ansemia  and  great  fretfulness,  and  there 
is  sometimes  a  little  fever. 

Skin-affections  may  be  absent,  but  are  usually  seen  in  some  degree, 
appearing  somewhat  later  than  the  coryza.  The  inner  surfaces  of  the 
nates  and  of  the  thighs  and,  next,  the  neighbourhood  of  the  eyebrows,  nose 
and  lips  are  most  often  occupied,  small  patches  of  erythema,  which  may 
quickly  coalesce  and  soon  take  on  a  shiny  or  a  coppery  appearance,  being 
the  most  frequent  form.  The  skin  of  the  palms  and  soles  is  often  red 
and  freely  desquamates,  and  sometimes  there  is  a  diffused  scaling  over 
large  areas,  most  marked  on  the  extremities.  As  in  adults,  the  flexures 
and  other  parts  exposed  to  any  kind  of  irritation  are  most  likely  to  suffer 
from  syphilitic  dermatitis  in  any  of  its  forms. 

Papular  rashes  are  common  and  may  be  very  extensive.  At  the 
corners  of  the  mouth  and  nose,  round  the  anus,  or  in  other  places 
subject  to  friction  and  moisture,  they  are  apt  to  develop  into  raised 
patches  known  as  "  mucous  tubercles "  or  "  condylomata,"  and  often 
become  fissured  and  ulcerated.  Such  patches  are  certainly  not  seldom 
seen  in  very  early  cases,  appearing,  however,  most  generally  after  a  few 
months.     Besides  this  affection  at  the  corners  of  the  mouth  there  are 


I  3  2  GENERAL  DISEASES. 

often  vertical  fissures  along  the  lips,  extending  sometimes  from  the  neigh- 
bouring skin  which  may  be  ulcerated  and  crusted.  Ulceration  in  the 
mouth  and  fauces  is  frequent,  the  gums,  tongue  and  tonsils  being  espe- 
cially affected.  Slight  enlargement  with  hardening  of  the  lymphatic 
glands  in  the  neck,  arm-pits  and  groins  is  very  common  after  the  lapse  of 
some  time,  and  the  nails  may  suffer  from  suppuration  of  the  matrix  or 
from  Assuring  without  ulceration.  Pustular  eruptions,  taking  on  some- 
times a  bullous  form,  are  not  rare,  and  are  generally,  according  to  my 
experience,  the  mark  of  grave  or  fatal  cases. 

Eoughly  speaking,  the  syphilitic  rashes  in  childhood  correspond  to 
those  in  adults  and  very  often  require  concomitant  symptoms  of  the 
disease  to  establish  their  true  character.  It  is  especially  difficult  to 
distinguish  some  of  the  slighter  forms  of  syphilitic  erythema  on  the 
buttocks  and  pudenda  from  the  results  of  irritation  and  excremental 
soakage,  aggravated  often  by  neglect  and  friction  with  hard  napkins. 
When  marked  erythema  spreads  far  down  the  lower  extremities  its 
syphilitic  origin  is  very  probable,  and  the  more  papular  in  character  it 
is,  whether  extensive  or  not,  the  stronger  this  probability  becomes. 

In  concluding  these  brief  allusions  to  cutaneous  syphilis  I  must  record 
a  warning  to  exercise  the  utmost  care  in  differentiating  between  syphilitic 
rashes  and  those  which  mark  the  exanthematic  fevers.  Mistakes  are 
sometimes  made  in  this  matter  by  the  expert  as  well  as  by  the  igno- 
ramus in  dermatology,  as  the  officers  of  fever  hospitals  well  know.  One 
important  lesson  to  be  learned  is  not  to  trust  too  much  to  the  appearance 
of  the  rash  for  the  necessary  differentiation,  but  to  rely  mainly  on  a 
thorough  examination  and  careful  consideration  of  the  case  in  all  its 
aspects,  not  forgetting  to  give  due  weight  to  its  history. 

Late  dentition  or  the  rapid  decay  of  normally  evolved  teeth  may  be 
among  the  results  of  infantile  syphilis.  I  have  observed  this  in  cases 
where  there  was  no  appearance  of  rickets,  but  it  must  nevertheless  be 
borne  in  mind  that  syphilitic  malnutrition  frequently  prepares  the  way 
for  rickety  developments.  Iritis  is  but  rarely  seen  until  after  infancy, 
but  slight  cases  may  be  easily  overlooked.  The  bones  are  often  affected 
in  the  cases  which  are  still-born  or  soon  die,  and  sometimes  in  those 
which  survive.  It  is  chiefly  the  long  bones  which  suffer,  at  the  junction 
of  the  epiphysis  with  the  shaft.  The  inflammatory  process  may  cause 
enlargement,  and  sometimes  suppuration  with  complete  separation  of  the 
epiphysis.  Loss  of  movement  of  the  extremities,  known  as  syphilitic 
pseudo-paralysis,  chiefly  affecting  the  arms  is  occasionally  seen,  with  or 
without  epiphysial  enlargement,  but  always  with  evidence  of  tenderness, 
which  may  indeed  be  the  first  observed  symptom.  The  skull  may  be 
bossed  with  periosteal  or  bony  overgrowth,  especially  in  the  neighbour- 
hood of  the  anterior  fontanelle,  giving  rise  to  the  appearance  known  as- 


SYPHILIS.  I  3  3 

"natiform."  I  know,  however,  of  no  condition  of  the  infantile  skull, 
recognisable  during  life,  which  may  not  occur  in  cases  of  rickets  quite 
unmarked  by  any  sign  of  syphilis.  As  to  the  well-known  cranio-tabes 
or  localised  thinning  of  the  skull,  especially  in  the  occipital  and  posterior 
parietal  regions,  I  can  state  from  numerous  observations,  made  after  the 
publication  of  the  researches  of  Drs.  Barlow  and  Lees  on  this  point,  that 
it  is  not  often  found  in  cases  where  syphilis  can  be  excluded,  and  I 
therefore  agree  with  those  who  regard  this  phenomenon  as  a  much  more 
probable  mark  of  syphilis  than  of  rickets.  In  differentiating  between 
the  bone-deformities  of  rickets  and  syphilis  it  must  be  borne  in  mind 
that  the  syphilitic  affection  shows  itself  almost  always  long  before  the 
sixth  month,  the  rickety  but  rarely  before  the  eighth  or  ninth ;  while 
with  the  former  there  is,  as  a  rule,  other  marked  evidence  of  syphilis. 

A  peculiar  form  of  affection  of  one  or  more  phalanges  of  the  hand 
or  foot,  especially  of  the  proximal,  is  not  uncommon,  and  is  known 
as  "dactylitis  syphilitica."  The  skin  tends  to  become  involved  and 
there  may  be  suppuration.  Sometimes  the  metacarpal  bones  are 
diseased.  These  appearances  are,  however,  not  easy  to  distinguish 
from  those  occurring  without  evidence  of  syphilis  and  known  as  stru- 
mous dactylitis. 

Definite  local  symptoms  of  disease  in  the  nerve  centres  are  not  of  very 
great  frequency  in  syphilitic  infants.  The  sleeplessness,  which  is  common, 
and  the  headache,  which  to  all  appearance  not  seldom  exists,  may  probably 
be  accounted  for  by  pain  in  the  bones.  Chronic  hydrocephalus  is  often 
preceded  by  definite  signs  of  syphilis,  and  I  believe,  though  I  cannot 
prove,  that  this  affection  is  largely  of  syphilitic  origin,  in  spite  of  the 
popular  objection  that  it  does  not  yield  to  "  specific  "  treatment. 

There  are  enough  recorded  cases  both  of  hemiplegia  and  one-sided 
convulsions  in  markedly  syphilitic  infants  to  establish  a  reasonable  belief 
in  a  syphilitic  causation,  the  lesion  being  probably  a  localised  arteritis. 
I  have  seen  several  cases  of  this  kind,  including  one  of  four  years  old  with 
typical  aphasia,  where  the  symptoms  have  either  completely  or  partially 
disappeared  concomitantly  with  treatment  by  iodide  of  potassium,  and 
others  which  have  persisted,  with  rigid  contractures,  under  the  same 
regime.  I  have  never  treated  such  cases  without  "  specific  "  drugs,  but 
in  two  instances  in  adults  who  were  definitely  known  to  me  as  syphilitic, 
both  from  history  and  subsequent  symptoms,  typical  hemiplegia  soon 
passed  away  without  any  "  specific  "  treatment,  the  origin  of  the  attacks 
being  unsuspected  by  those  in  charge  at  the  time.  Other  paralyses  of 
separate  nerves,  one  or  more,  may  occur  in  childhood  as  in  adults,  and 
several  cases  have  been  recorded  of  mental  deficiency,  sometimes  con- 
genital but  more  often  of  later  appearance,  in  connexion  with  infantile 
syphilis.     Epilepsy  seems   sometimes  to  be  referable    to   this   disease. 


134  GENERAL  DISEASES. 

Generally  speaking,  irregularly  distributed  and  multiple  nervous  symp- 
toms should  always  excite  a  suspicion  of  syphilis. 

In  this  context  and  in  illustration  of  some  other  points  I  subjoin  a 
short  account  of  a  remarkable  case  of  late  "wasting  with  convulsions  in 
a  deeply  syphilitic  child  who  ultimately  recovered  good  health,  though 
with  much  cerebral  impairment. 

A  boy,  aged  three,  was  admitted  suffering  from  great  emaciation  of 
four  months'  duration  and  from  frequent  fits,  headache,  pains  in  the 
limbs,  occasional  vomiting,  and  some  diarrhoea  of  much  more  recent  date. 
He  was  an  eight-months  child,  bom  with  a  "  blistery  "  eruption  on  hands 
and  feet  followed  by  bad  snuffles  and  a  red  rash  on  his  buttocks.  He 
was  persistently  treated  at  a  metropolitan  hospital  with  grey  powders 
from  the  first  week  up  to  the  eighteenth  month  of  his  life.  He  never 
had  any  other  illness.  He  cut  his  first  teeth  at  fourteen  months,  first 
walked  at  2\  years,  and  never  talked  much.  His  father  had  suffered 
very  frequently  from  sore  throat  and  ulcers  on  his  tongue.  His  mother, 
aged  28,  had  never  been  ill  and  looked  healthy.  She  had  had  two  mis- 
carriages, one  still-birth,  two  children  who  had  lived  a  few  hours  and 
one  who  had  lived  ten  weeks.  One  besides  the  patient  was  alive,  aged 
nine  months,  suffering  from  snuffles,  eruption  and  anal  condylomata.  On 
admission  the  boy  was  found  to  be  unable  to  utter  sentences,  but  appeared 
to  understand  most  that  was  said  to  him.  The  temperature  was  normal. 
He  had  recently  had  sixty-one  fits  in  forty-eight  hours.  Soon  after 
admission  he  had  a  general  convulsion,  the  right  side  being  chiefly 
affected,  and,  a  few  days  afterwards,  eight  similar  attacks  in  quick  succes- 
sion. In  the  intervals  he  lay  on  his  back  apparently  unconscious,  with 
flexion  of  arms,  thighs  and  legs,  and  rigidity  of  the  limbs  much  more 
marked  on  the  right.  After  a  few  days  he  became  sensible,  but  the 
already  excessive  wasting  increased,  and  the  rigidity  of  limbs,  though 
less,  continued.  In  this  condition  he  remained  for  three  months 
when,  with  some  very  slight  improvement  in  nutrition,  he  was  taken 
home.  A  year  afterwards  he  was  brought  again.  He  was  then  a  bright 
pleasant-looking  well-nourished  boy,  but  could  not  talk  and  seemed  very 
deficient  in  intelligence.  He  could  move  all  his  limbs  freely  in  bed, 
though  the  left  leg  was  always  kept  partially  flexed,  and  there  was  no 
wasting  or  rigidity  in  any  part.  But  he  was  entirely  unable  to  stand 
or  sit,  and  always  passed  urine  and  faeces  under  him.  After  six  weeks 
he  went  home  in  the  same  condition. 

Early  demonstrable  enlargement  of  the  spleen  and  liver,  or,  I  think, 
more  often  of  the  spleen  alone,  is  common,  especially  in  otherwise  grave 
cases.  The  liver  is  hard  from  interstitial  inflammation  or  may  contain 
isolated  growths.  I  have  seen  a  case  with  jaundice  where  the  liver  was 
studded  with   softening   gummata,  the  portal  fissure   being  involved. 


SYPHILIS.  I  3  5 

It  is  possible  that  many  of  the  cases,  familiar  to  us  among  the  infants 
of  the  poor,  and  otherwise  ill  understood,  of  fatal  anaemia  with  much 
enlarged  spleen  but  without  leucocythseniia,  are  of  syphilitic  origin ;  and 
it  is  certain  that  the  spleen  is  enlarged,  and  sometimes  excessively,  in  a 
considerable  proportion  of  syphilitic  infants. 

The  lungs,  heart,  kidneys,  and  testicles  are  occasionally  found  to  be 
the  seat  of  fibroid  disease  of  probably  syphilitic  origin ;  and  the  involve- 
ment of  the  pancreas  seen,  according  to  some  authorities,  in  some  of  the 
worst  cases,  may  help  to  explain  the  gravity  of  their  course,  and  indicate 
the  possibility  of  the  digestive  disorders  in  the  less  severe  and  more 
chronic  cases  of  malnutrition  being  connected  with  impaired  function  of 
this  organ. 

As  an  illustration  of  congenital  syphilis  with  renal  disease  I  may  quote 
the  following  case.  A  boy  of  nine  months  old,  who  had  had  snuffles 
soon  after  birth  and  whose  mother  had  had  three  miscarriages,  Avas 
admitted  with  a  history  of  wasting  and  cedema  of  all  extremities  of  six 
weeks',  and  a  rash  on  the  buttocks  of  three  weeks',  duration.  He  had 
general  anasarca  and  a  dark  red  scaly  eruption  on  the  buttocks  and  the 
inner  side  of  the  thighs,  but  no  albuminuria.  After  a  week  the  child 
had  a  convulsive  fit,  affecting  the  right  side,  with  some  rigidity,  and 
became  unconscious.  jSo  urine  had  been  passed  for  several  hours.  He 
was  put  in  a  hot  bath,  but  very  soon  died.  Recent  collapse  was  found 
at  both  pulmonary  bases,  and  the  kidneys  were  extremely  tough  with 
wasted  cortex  and  somewhat  adherent  capsules,  containing  also  a  few 
very  minute  calcidi.     The  brain  appeared  quite  normal. 

In  all  probability  some  cases  of  purpura  may  be  explained  by  syphilis. 
Among  others  I  have  seen  a  case  of  chronic  malnutrition  eighteen  months 
old,  with  extensive  external  and  internal  haemorrhages,  enlarged  spleen, 
and  bossy  skull,  in  which  there  was  a  history  of  marked  snuffles  and 
characteristic  rash  soon  after  birth.  Syphilis,  it  must  be  remembered,  is 
a  profound  disturber  of  tissue-nutrition  generally.  Many  children  are 
seen  after  all  definitely  recognisable  specific  symptoms  have  disappeared, 
and  I  have  noticed  in  them,  more  often  than  in  adults,  how  great  the 
disproportion  may  be  between  the  marked  wasting  and  cachectic  appear- 
ance presented  and  the  slight  degree  of  malaise  or  debility  evinced  or 
complained  of.  Equal  wasting  due  to  deficient  food  or  to  gastro-intestinal 
disturbance  would  bave  inevitably  brought  down  the  cases  I  speak  of  to 
a  much  lower  level  of  vitality.  "When  inquiry  reveals  the  cause  of  this 
condition  appropriate  treatment  may  often  lead  to  great  improvement  or 
complete  recovery,  but  in  some  cases  that  I  have  seen  at  various  ages 
there  has  been  permanent  stunting  of  growth,  children  of  seven  or  eight 
years  old  being  emaciated  and  of  the  stature  of  half  their  age,  without 
any  trace  of  rickets  or  other  deformity. 


I36  GENERAL  DISEASES. 

I  have  known  a  considerable  number  of  syphilitic  and  wasted  infants 
which,  without  much  or  any  skin-affection  or  any  pyrexia,  steadily  deterio- 
rated, in  spite  of  all  treatment,  and  were  found  after  death  to  be  the 
subjects  of  advanced  but  unexpected  tuberculosis  of  the  peritoneum 
or  intestines.  A  few  others,  with  but  indistinctive  physical  signs,  had 
extensive  tuberculosis  of  the  lungs  and  pleura.  With  few  exceptions, 
however,  tuberculosis  of  the  lungs  is  accompanied  by  more  or  less  fever. 

Relapse  of  infantile  syphilis  is  said  by  most  authorities  to  be  rare,  but 
this  statement  is  vague,  of  little  meaning,  and  incapable  of  proof.  I 
believe  on  the  contrary  that,  in  one  form  or  other,  symptoms  of  infantile 
syphilis  are  very  apt  to  recur.  It  is  true  that  the  majority  of  cases  either 
die  early  or  apparently  recover  while  under  observation  and  treatment, 
many  of  the  latter  class  showing,  perhaps  for  long,  no  further  symptom, 
and  many  in  all  probability  remaining  perfectly  well.  But  in  hospital 
practice,  on  which  most  large  statistics  and  important  records  must  be 
based,  the  cases  are  not  long  enough  under  observation  to  justify  the  pre- 
valent dogmatism  on  this  question.  Among  other  cases  I  have  seen  one 
of  marked  syphilitic  snuffles,  with  laryngitis  and  skin-affection,  become 
rapidly  well  while  under  treatment  with  mercury  which  was  continued 
for  many  weeks  before  discharge.  It  was  re-admitted  three  months 
later  with  fresh  eruption,  and  marked  cranio-tabes  which  was  certainly 
absent  before.  The  apparent  frequency  of  unrelapsing  syphilis  in  infants 
accounts  largely  for  the  oft-repeated  statement  of  the  much  greater  success 
of  mercurial  treatment  at  this  age  than  in  later  years,  the  true  explana- 
tion of  the  element  of  fact  in  this  clinical  observation  being  rather,  I 
apprehend,  that,  when  the  syphilitic  poison  is  not  enough  to  kill,  it  is 
more  readily  thrown  off  during  the  active  metabolism  of  early  life.  In 
some  cases  syphilitic  symptoms  continue  to  recur  from  infancy  to  later 
age,  however  treated,  of  which  I  have  seen  a  few  examples  with  grave  and 
multiform  effects.  In  others,  conventionally  known  as  "  late  hereditary 
syphilis,"  there  is  an  interval  of  several  years  before  fresh  manifestations 
are  noticed,  or  symptoms  may  be  seen  for  the  first  time  as  late  as  from 
after  the  second  dentition  to  puberty,  with  no  obtainable  history  of  an 
infantile  attack. 

In  late  hereditary  syphilis,  of  which  I  found  38  cases  recorded  as 
such  in  my  note-books,  whether  preceded  or  not  by  a  definite  infantile 
attack,  stunted  growth  and  deficient  mental  development  are  not  seldom 
seen  and  are  probably  far  more  frequent  than  reported.  Such  cases 
seem  never  to  have  been  able  to  regain  the  ground  lost  during  the  tissue- 
starvation  of  their  earliest  years.  The  skull  may  be  bossed  on  the  fore- 
head or  the  sides  or  round  the  anterior  fontanelle,  or  there  may  be  a 
marked  prominence  along  the  line  of  the  frontal  suture ;  the  head  may 
be  square  and  flat  at  the  top ;  or  there  may  be  chronic  hydrocephalus. 


SYPHILIS.  137 

The  bridge  of  the  nose  is  usually  depressed,  being  either  destroyed  by 
old  ulceration  or  congonitally  flat  without  bone-disease.  Bony  enlarge- 
ments, especially  of  the  arms  and  legs,  are  frequently  seen,  the  tibiae  being 
often  apparently  bowed.  The  peg-top  and  notched  teeth  and  the  inter- 
stitial keratitis  described  by  Hutchinson  are  frequently  seen,  and  are 
among  the  most  valuable  indications  of  syphilis.  Iritis  and  choroi- 
ditis are  less  common.  Sometimes,  though  rarely,  complete  blindness  is 
caused  by  atrophy  of  the  discs.  Necrosis  of  bones,  nodes,  ulcerating 
gummata  and  other  affections  similar  to  what  is  known  as  tertiary 
syphilis  in  the  adult  may  occur,  and  suppuration  of  the  middle  ear  is 
frequent.  There  is  also  a  form  of  deafness  which  may  appear  almost 
suddenly  and  become  complete  with  no  detectable  lesion.  It  is  said 
indeed  by  some  authorities  that  syphilis  is  a  common  cause  of  con- 
genital deaf-mutism.  Severe  headaches,  especially  vertical  and  temporal, 
are  very  frequent,  and  pain  in  the  long  bones  is  often  complained  of. 
In  a  girl  of  twelve,  with  distinct  Hutchinsonian  teeth  and  a  definite 
history  of  infantile  syphilis,  who  suffered  from  epilepsy  and  choroiditis 
with  atrophy  of  discs  going  on  to  complete  blindness,  there  was  well- 
marked  spastic  paraplegia ;  and  in  two  other  cases  very  similar  to  this 
there  was  a  high  grade  of  imbecility  in  addition.  It  must  be  admitted 
that  it  is  sometimes  difficult  to  make  a  diagnosis  between  late  syphilis 
and  so-called  "  scrofula,"  especially  in  bone-  or  joint-diseases  without 
a  history  of  infantile  syphilis,  and  some  of  the  bony  deformities  attri- 
buted to  syphilis  are  indistinguishable  from  those  due  to  rickets. 
Those  who  are  content  to  infer  the  cause  of  mischief  from  the  effects 
of  specific  treatment  are  not  much  aided  here,  for  the  later  manifesta- 
tions of  syphilis  of  whatever  kind  and  at  all  ages  are  notoriously  often 
recalcitrant  to  all  medication. 

The  prognosis  in  infantile  syphilis  is  really  good  only  in  those  cases 
where  the  general  nutrition  is  not  greatly  impaired  and  the  skin-affection 
not  extensive.  In  a  vast  number  of  cases  death  follows  sooner  or  later 
on  malnutrition  with  marked  dulness  and  inelasticity  of  skin,  even  when 
other  specific  signs,  cutaneous  or  otherwise,  are  slight  or  almost  absent. 
In  cases  where  a  child  wastes  almost  from  birth,  with  an  appear- 
ance of  skin  at  all  suggestive  of  syphilis,  the  prognosis  must  be  very 
guarded,  and,  when  more  definite  specific  signs  supervene,  mostly  un- 
favourable. Pustular  eruptions  have  a  bad  significance  even  when  not 
extensive,  being  usually  associated  with  obstinate  wasting,  and  gastro- 
intestinal and  pulmonary  attacks  much  increase  the  gravity  of  all  cases. 
The  very  numerous  and  slighter  instances  which  are  seen  in  out-patient 
practice,  and  at  least  apparently  recover,  form  the  main  basis  of  most 
clinical  accounts  of  infantile  syphilis,  and  the  fatality  of  the  disease 
as  a  whole  is  thus  perhaps  scarcely  realised  by  many  readers  of  text- 


138  GENERAL  DISEASES. 

Looks,  or  "by  those  who  have  not  had  experience  at  hospitals  where 
the  youngest  infants  of  the  poorest  classes  in  large  towns  are  freely 
admitted.  Out  of  a  series  of  286  syphilitic  infants  admitted  as  such  into 
the  wards  of  Shadwell  Hospital  and  treated  in  nearly  all  instances  hy 
mercury  from  the  outset,  certain  cases  having  potassium  iodide  as  well, 
173  died.     A  large  majority  of  these  were  under  six  months  old. 

The  proper  treatment  of  syphilis  consists  in  endeavouring  to  improve 
nutrition,  and  to  arrest  symptoms  whether  clearly  specific  or  not.  The 
diet  should,  therefore,  he  most  carefully  arranged  on  general  principles 
and  to  suit  each  individual  case,  and,  likewise,  all  gastro-intestinal  symp- 
toms, such  as  vomiting  and  diarrhoea,  should  he  treated  as  they  arise.  Cod- 
liver  oil,  iron  and  arsenic  are  often  quite  invaluable  aids.  The  patient 
should  he  kept  perfectly  clean  and  warm  and  should  have  the  benefit, 
with  due  precautions,  of  all  possible  fresh  air  and  sunlight.  In  all  bad 
cases,  where  rapid  improvement  does  not  set  in  within  a  few  days  of 
their  coming  under  care,  I  have  been  in  the  habit  of  giving  mercury  in 
some  form — usually  the  Pulvis  Hydrargyri  cum  creta  in  daily  quantities 
of  from  one  to  three  grains,  increased  according  to  age — as  also  in  all 
cases,  however  good  their  nutrition  may  be,  where  any  specific  lesions 
persist.  The  Liquor  Hydrargyri  perchloridi  may  similarly  be  given 
in  quantities  varying  from  half  a  drachm  to  a  drachm  a  day.  There  is 
no  doubt  that  many  syphilitic  events  can  be  lessened  or  abolished  by 
mercury  or  iodide  of  potassium,  the  latter  drug  being  especially  useful 
when  there  is  active  ulceration  of  mucous  membranes  or  evidence 
of  bone  or  periosteal  mischief.  I  must  however  record  my  strong 
opinion  that  the  question  of  the  power  of  mercury  in  eradicating  or 
"curing"  the  disease  appears  to  me,  after  long  experience  and  reflection, 
to  be  no  nearer  solution  from  the  results  of  treatment  of  infantile  syphilis 
by  this  drug.  Syphilis,  however  treated,  is  a  very  malignant  and  fatal 
disease  in  infancy.  In  the  less  severe  cases,  characterized  mainly  by 
snuffles  and  slight  eruptions  chiefly  confined  to  the  nates  and  pudenda, 
recovery,  which  is  frequent,  is  usually  put  down  to  the  mercurials 
almost  always  prescribed.  I  know,  however,  from  experience  that  many 
such  cases  recover  equally  well  without  mercurial  treatment ;  and  also 
that  definite  symptoms  may  make  their  appearance  while  mercury  is 
being  given  in  full  doses  on  mere  suspicion  of  syphilis,  and  may  mark 
a  severe  or  even  fatal  course  of  the  disease.  I  would  particularly 
remark  here  that  it  is  only  in  comparatively  few  (though  numerically 
many)  of  my  cases,  and  such  only  as  I  have  above  alluded  to,  that  I  have 
omitted  the  orthodox  treatment,  almost  all  the  fatal  ones  having  had 
mercury  systematically  from  the  beginning,  and  many  having  been  already 
under  such  treatment  as  out-patients.  I  believe  that  the  effects  of 
mercury  and  potassium  iodide  on  syphilitic  manifestations  is  no  greater 


SYPHILIS.  139 

in  infants  than  in  adults  ;  that,  as  proved  hy  the  common  mortality 
of  the  infantile  disease  however  treated,  it  is  certainly  not  more  curable 
but  rather  much  more  serious  than  at  a  later  age,  owing  to  the  profound 
malnutrition  it  engenders ;  and  that  the  much  greater  number  of  appa- 
rently or  really  complete  recoveries  in  infancy  is  due  to  the  more  ready 
throwing  off  of  a  less  than  lethal  quantity  of  poison  during  the  active 
metabolism  of  early  life. 

I  agree  with  the  somewhat  inconsistent  practice  of  some  of  the  most 
thorough-going  advocates  of  mercury  in  discontinuing  the  drug  very  soon 
after  the  subsidence  of  specific  symptoms,  differing  herein  from  other 
believers  in  the  antidotal  powers  of  the  drug  who  logically  urge  a  more 
continued  course  of  treatment.  Such  a  course,  in  my  opinion,  is  even  more 
often  decidedly  harmful  to  infants  than  to  adults,  and  I  have  seen  several 
cases  rapidly  improve  when  a  long  mercurial  course  was  discontinued. 

I  substitute  mercurial  inunction  for  internal  treatment  only  when 
the  latter  seems  to  disagree,  although  I  have  little  reason  to  believe  that 
inunction  in  such  cases  is  much  more  appropriate.  I  find  potassium 
iodide  as  markedly  useful  in  checking  symptoms  as  it  is  with  adults, 
even  in  cases  which  ultimately  waste  and  die ;  and  both  in  adults  and 
infants  I  frequently  prescribe  this  drug  with  success  when  symptoms 
are  active  and  increasing,  regardless  of  all  doctrinal  rules  as  to  the 
so-called  secondary  or  tertiary  stage  of  the  disease.  "While  somewhat 
narrowing,  then,  the  therapeutic  field  of  mercury  I  would  widen  that 
of  the  iodide,  as  defined  in  each  case  by  most  syphilologists. 

For  severe  mucous  ulcers  and  skin-eruptions  which  do  not  tend  to 
heal  quickly  the  best  applications  are  calomel  powder,  the  ammoniated 
mercury  ointment,  or  various  dilutions  of  the  nitrate  of  mercury  oint- 
ment, the  efficacy  of  which  is  often  very  manifest  in  lesions  other  than 
syphilitic. 

I  have  written  thus  on  the  specific  treatment  of  syphilis  in  order  to 
emphasise  my  strong  conviction  that,  important  and  often  indispensable 
as  mercurials  may  be,  Ave  must  never  forget  the  paramount  duty  of 
endeavouring  to  improve  the  general  nutrition  in  syphilis  by  all  available 
means.  Simply  to  prescribe  mercurials  for  syphilitic  babies  without 
insisting  strongly  on  general  treatment  and  improved  hygiene  is,  in  my 
belief,  little  more  than  trifling  at  the  best. 


140  GENERAL  DISEASES. 


CHAPTER  III. 

SCROFULOSIS    OR   STRUMA. 

In  speaking  of  this  subject  at  the  present  day,  when  precise  conceptions 
and  definite  statements  in  pathology  are  justly  demanded,  we  are  met  by 
many  and  diverse  difficulties.  Not  the  least  of  these  are  the  demon- 
strated facts  of  the  identity  or  similarity  of  the  anatomical  processes  in 
affections  formerly  known  as  "  scrofulous  "  and  "  tubercular  "  respectively, 
and  the  ascertained  presence  of  the  bacillus  of  tubercle  in  many  morbid 
products,  such  as  for  instance  in  those  of  joint-  and  bone-disease,  which 
were  previously  described  as  "  strumous  "  and  regarded  as  a  class  apart. 
In  a  practical  work,  however,  confined  to  disease  in  childhood  where 
scrofulosis  and  tuberculosis  or,  according  to  the  now  prevalent  nomen- 
clature, tuberculosis  alone  figures  so  pre-eminently,  it  is  perhaps  less 
necessary  to  express  a  dogmatic  creed  on  the  difficult  pathological  questions 
involved  in  this  subject,  and  more  excusable  to  refrain  from  any  detailed 
discussion  thereon.  I  shall  therefore  only  say  that  I  cannot  regard  the 
presence  of  the  tubercle  bacillus  as  demonstrating  the  setiological  identity 
of  all  morbid  processes  with  which  it  may  be  found  associated.  It  is 
clear  that  the  causal  role  of  this  bacillus  is  of  a  different  kind  from  that 
of  the  assumed  organic  germs  of  such  affections  as  the  acute  infectious 
fevers,  seeing  that  both  "  predisposition  "  and  well-recognised  favouring 
conditions  for  its  reception  and  growth  are  so  prominent  in  the  matter 
of  tuberculous  disease ;  and,  for  all  practical  purposes,  it  can  scarcely  be 
denied  that  an  isolated  and  chronic  affection  of  a  single  joint,  in  a  body 
proved  by  post-mortem  examination  to  be  entirely  free  from  tubercle  or 
any  disease  elsewhere,  is  not  to  be  classed  clinically  with  the  familiar 
affection  known  as  general  tuberculosis.  The  definite  limitation  of  some 
eases  of  local  disease  in  which  tubercle  is  found  seems  to  be  in  itself  a 
more  important  pathological  fact  in  the  setiological  study  of  the  case  than 
the  mere  presence  of  the  tubercle  bacillus  ;  while,  on  the  other  hand,  the 
development  of  tubercle  in  cases  clinically  described  as  general  tuber- 
culosis seems  to  dominate  or  supplant  most  other  causal  considerations. 

Without  therefore  discussing  the  still  bewildering  question  of  how 
tubercle  is  related  to  the  various  "  inflammatory  "  and  "  caseous "  pro- 
cesses with  which  it  is  frequently  associated,  or  whether  all  caseation  is 
of  ultimately  tubercular  origin  or  not,  I  must  incur  the  condemnation  of 
many  modern  exponents  of  a  perhaps  premature  finality  in  this  patho- 
logical matter  by  simply  stating  that  I  still  recognise  a  marked   and 


SCROFULOSIS  OR  STRUMA.  I  4  I 

clinically  useful  difference  between  scrofulosis  and  "  tuberculosis "  as 
presently  to  be  described,  although  I  am  fully  convinced  of  the  long- 
known  and  excessively  frequent  association  of  the  scrofulous  habit  with 
what  is  now  regarded  as  the  infection  of  tubercle.  I  cannot  see  my 
way  to  dispense  altogether  with  the  old  conception  of  "  diathesis  "  or 
"  tendency,"  which  is  nevertheless  open  to  a  perhaps  hypercritical  charge 
of  want  of  precision. 

By  the  clinical  term  scrofulosis  I  would  indicate  a  largely  hereditary 
tendency  to  congestion  and  inflammation  of  various  parts  and  organs, 
which  is  especially  marked  in  the   lymphatic   structures  and  glands. 
Imperfect  nutrition  and  circulation  underlie  these  morbid  expressions, 
which  are  seen  chiefly  in  children  born  and  reared  in  bad  hygienic  con- 
ditions with,  frequently,  a  vicious  heredity  as  well.     Parental  syphilis 
and  phthisis  underlie  struma  in  numerous  cases,  while  bad  food  and 
the  deprivation  of  pure  air  and  light  are  probably  guilty  of  many  more. 
Tonsillar  enlargement,  with  recurring  inflammation,  is  a  common  mark  of 
this  condition,  mostly  accompanied  by  a  similar  affection  of  the  glands 
of  the  neck.     These  glands  may  only  swell  and  after  a  while  subside,  but 
frequently  suppurate,  and  then  nearly  always  become  more  or  less  caseous. 
In  close  connection  with  this  glandular  affection  we  find  disease  of  bone, 
swelling  of  joints,  and  various  affections  of  the  skin  and  mucous  mem- 
branes.    Now,  although  we  know  that  general  tuberculosis  and  acute 
tuberculosis  of  certain  organs  are  frequent  events  in  the  "  scrofulosis  " 
above  described,  and  that  we  can  draw  no  important  histological  or  other 
pathological  line  between  the  cases  we  call  scrofulous,  where  there  is 
caseation,  and  those  we  call  tubercular,  both  the  microscopical  and  bacillary 
evidence  of  tubercle  being  mostly  found  in  all,  yet  there  is  a  vast  number 
of  "  scrofulous "  children  who  never  become  the  subjects  of  general  or 
acute  tuberculosis,  and  seem  therefore  to  be  proof  against  the  special 
infective  action  of  tubercle  which  is  so  marked  in  other  cases.     It  is 
believed  by  some  that  caseation  is  a  mark  of  the  local  entry  of  tubercle. 
Whether  this  be  so  or  not  it  is  certainly  indicated  by  many  inoculatory 
experiments  that  many  of  the  non-caseous  processes  in  the  skin  and 
mucous  membrane  of  the  so-called  scrofulous  have  no  power  of  tuber- 
cular infectiveness.     It  may  probably,  then,  be  held  that  caseation  is  a 
result  of  more  morbid  processes  than  one  ;  that  there  is  a  class  of  cases 
denoted  by  the  term  "  scrofula  "  which  is  marked  by  a  great  liability  to 
inflammatory  enlargement  of  glands  and  lymphatic  structures  generally, 
arising  from  conditions  of  malnutrition  both  hereditary  and  acquired  ; 
that  the  inflammatory  process  in  many  of  these  cases  is  exceedingly  apt  to 
become  caseous  ;  and  that  in  caseation,  while  there  is  an  evident  risk  of 
the  occurrence  of  acute  or  general  tuberculosis,  the  process  very  frequently 
remains  absolutely  localised  and  its  products  become  entirely  obsolete. 


142  GENERAL  DISEASES. 

It  is  especially,  I  think,  in  the  glands  of  the  neck  that  well-marked  and 
long-standing  caseation  is  so  often  seen  to  become  ultimately  obsolete, 
with  no  subsequent  outbreaks  of  tuberculosis  or  lung-disease  during 
even  a  long  life ;  and  the  same  may  be  said  of  many  of  the  numerous 
cases  of  bone-  and  joint-mischief  now  so  generally  classed  as  tuber- 
cular by  surgeons.  It  must  happen  to  many  hospital  physicians  to  be 
frequently  asked  by  their  surgical  colleagues  to  report  medically  on  such 
cases,  and  almost  as  frequently  to  find,  to  the  apparent  surprise  of  the 
surgeon,  no  evidence  whatever  of  tuberculosis  elsewhere. 

The  chief  mark  of  so-called  scrofulous  inflammation,  as  distinguished 
from  that  occurring  in  healthy  children  as  the  result  of  irritation,  is 
chronicity.  This  is  well  seen  in  the  common  affection  of  the  glands  of 
the  neck  in  children.  Added  to  this  there  is  a  dominant  tendency  to 
catarrh  of  mucous  membranes.  Intestinal  and  perhaps  gastric  catarrh  is 
common,  often  accompanied  by  fever,  and  intestinal  ulceration  may  ensue. 
Nasal  catarrh  may  be  obstinate,  as  also  ozoena  with  chronic  bone-disease. 

There  may  be  tarsal  or  general  ophthalmia,  with  much  suppuration, 
keratitis,  and  all  grades  of  affection  of  the  pharynx  and  of  the  external 
and  middle  ears.  Bronchial  and  pulmonary  catarrh  are  prominent, 
ekzema  is  frequent,  and  slight  injuries  to  the  skin  may  cause  obstinate 
dermatitis.  Hard  painless  subcutaneous  lumps,  gradually  softening  and 
ultimately  discharging  cheesy  matter,  are  common  in  strumous  infants ; 
they  may  be  very  numerous  and  run  a  lengthened  course  before  finally 
cicatrising.  Lastly,  disease  of  the  bones  and  joints  must  be  mentioned, 
and  especially  the  familiar  caries  of  the  vertebra?,  which  in  its  earlier 
stage  so  often  comes  under  the  notice  of  the  physician.  The  pain  in 
this  disease  is  often  for  long  referred  to  other  parts  of  the  body  than  the 
spine  itself,  according  to  the  distribution  of  the  involved  nerves  ;  and 
the  early  diagnosis  is  to  be  made,  as  urged  by  Eustace  Smith  and  others, 
much  more  from  the  observation  of  increased  pain  on  movement  and  its 
abolition  by  rest,  and  from  careful  examination  of  the  attitudes  of  the 
child  and  the  mobility  of  his  spinal  column,  than  from  percussion  over 
the  vertebras  in  order  to  elicit  evidence  of  tenderness,  which  is  often 
absent  even  in  advanced  cases  of  caries. 

The  glandular  enlargements  in  the  thorax  or  abdomen  which  may 
occur  in  scrofulous  children  will  be  mentioned  elsewhere.  Just  as  the 
neck-glands  enlarge  mostly  in  association  with  pharyngeal  inflammation, 
so  the  thoracic  and  abdominal  glands  may  swell  and  caseate  owing  to 
catarrhal  inflammation  in  the  pulmonary  and  intestinal  tracts. 

The  old  description  of  the  general  appearance  of  strumous  children  as 
to  face  and  build  of  body  is  very  often  justified  ;  but  in  many  cases  it  is 
by  no  means  applicable,  pronounced  strumous  affection  being  seen  in 
children  of  very  different  appearance.     I  however  quite  agree  with  those 


SCROFULOSIS  OR  STRUMA.  I  43 

who  recognise  the  extreme  frequency,  in  cases  which  from  other  reasons 
may  be  regarded  as  strumous,  of  a  redundancy  of  hair  on  scalp  and  body, 
of  a  rough  and  often  scaly  skin,  and  of  rapid  growth  of  nails. 

The  greatest  danger  to  strumous  children  is  that  of  ensuing  tubercu- 
losis, whether  in  the  form  of  pulmonary  phthisis,  generally  after  the  age 
of  six  or  seven  years,  or  of  abdominal  or  cerebral  mischief  at  any  age. 
All  inflammatory  affections  and  diseases  of  infective  nature  have,  more- 
over, their  special  dangers  for  those  of  the  scrofulous  diathesis,  and  we 
have  seen  that  much  enlarged  glands  in  the  chest  and  abdomen,  induc- 
ing their  own  special  troubles,  may  result  from  pulmonary  or  intestinal 
catarrh.  At  the  same  time  large  numbers  of  markedly  strumous  children, 
and  especially  those  whose  main  affection  is  pharyngeal  with  enlarged 
cervical  glands,  make  a  good  recovery  and  enjoy  long  and  healthy  lives. 

The  general  treatment  of  struma  requires  much  attention  to  hygiene 
in  the  widest  sense.  The  child  should  have  abundance  of  sunlight 
and  fresh  air,  an  ample  diet,  regular  exercise,  and  daily  bathing  in  salt 
water.  Innutritious  ingesta,  such  as  sweets  &c,  between  meals  should 
be  strictly  forbidden,  and  all  care  taken  to  avoid  the  establishment  of 
depraved  appetite.  Dryness  of  climate  should  be  secured  when  possible, 
and  the  body-warmth  carefully  kept  up  by  efficient  clothing.  I  know 
no  better  home-resorts  for  strumous  children  than  some  of  the  East 
Coast  watering-places  such  as  Whitby,  Cromer,  Felixstowe,  Margate  or 
"Westgate,  in  the  summer,  and,  in  the  winter  and  early  spring,  Aberyst- 
wyth, Bournemouth,  and  Freshwater  or  SandoAvn  in  the  Isle  of  Wight; 
The  continuous  use  of  cod-liver  oil  should,  I  think,  always  be  advised, 
and  especially  insisted  on,  whenever  it  is  well  assimilated,  in  cases  with 
active  glandular  enlargement  or  signs  of  catarrh.  Iron  with  small  doses 
of  iodide  of  potassium,  or  the  syrup  of  the  iodide  of  iron,  should  also  be 
given.  Local  treatment  of  the  pharyngitis  and  tonsillitis,  which  gene- 
rally precede  enlargement  of  the  cervical  glands,  should  be  instituted 
early,  and  may  lessen  or  prevent  the  glandular  trouble.  If  the  glands 
be  already  much  enlarged,  and  especially  if  they  appear  to  be  caseous, 
little  can  be  expected  from  local  treatment  by  "absorbent"  unguents 
containing  either  iodine  or  mercury.  From  sufficient  experience,  and 
not  only  in  view  of  the  frequently  tubercular  relationships  or  sequelae 
of  these  glandular  affections,  I  am  entirely  in  accord  with  the  modern 
surgical  practice  of  enucleating  strumous  glands  in  their  early  stages. 
When  suppuration  sets  in  the  abscess  should  certainly  be  opened  at 
once,  and  never  allowed  to  burst.  All  breaches  of  surface,  spontaneous 
or  surgical,  in  scrofulous  children  should  be  carefully  cleansed  and  drained 
antiseptically ;  and  all  discharges  from  mucous  surfaces,  especially  from 
the  auditory  meatus,  should  be  treated  as  soon  as  possible  with  astringent 
applications. 


144  GENERAL  DISEASES. 


CHAPTEE    IV. 

TUBERCULOSIS. 

Much  of  the  clinical  subject-matter  of  tubercular  disease  is  set  forth,  for 
practical  purposes,  under  the  special  headings  of  cerebral,  thoracic  and 
abdominal  disorders.  It  is  nevertheless  to  be  borne  in  mind  that  the 
younger  the  subjects  the  wider  is  the  distribution  of  tubercle,  and,  more- 
over, that  in  a  large  number  of  cases  proved  at  death  to  be  general  tuber- 
culosis there  have  been  few  and  sometimes  no  local  signs  or  symptoms 
definitely  demonstrative  of  this  disease.  In  such  instances  the  diagnosis, 
depending  mainly  on  such  general  symptoms  as  wasting,  remittent  fever 
and  the  like,  is  often  doubtful  and  may  be  altogether  missed ;  while  in 
a  scarcely  less  number  of  instances  of  failing  nutrition,  with  or  without 
special  signs  or  symptoms,  tuberculosis  is  diagnosed  where  it  does  not 
exist.  There  are  also  some  cases  of  general  tuberculosis  which,  owing  to 
the  prominence  of  special  clinical  symptoms,  are  apt  to  be  regarded  under 
the  aspect  of  local  disease.  I  could  quote  numerous  examples,  where 
abundant  and  widely-distributed  tubercle  was  found  in  all  the  three 
great  cavities,  each  of  which  during  life  wore  the  semblance  of  either 
pulmonary,  abdominal  or,  though  rarely,  cerebral  disease  alone.  In 
illustration  of  the  proportionate  frequency  of  the  forms  of  tubercular 
disease,  as  regards  their  chief  clinical  characteristics,  I  have  referred  to 
a  series  of  400  in-patients  at  Shadwell  Hospital  registered  as  tubercular 
or  phthisical  either  on  clinical  or  post-mortem  evidence.  Of  these  about 
25  per  cent,  were  found  in  the  category  of  phthisis  or  pulmonary  tuber- 
culosis ;  2  5  per  cent,  in  that  of  general  tuberculosis  ;  1 2  per  cent,  in 
that  of  abdominal  tuberculosis,  mainly  peritonitis ;  and  the  remainder, 
38  per  cent.,  in  that  of  tubercular  meningitis  or  cerebral  tuberculosis. 
Tuberculosis  thus  described  forms  rather  over  5  per  cent,  of  all  admis- 
sions to  this  hospital. 

By  tuberculosis  we  understand  generally  a  specific  infectious  disease- 
characterized  by  the  presence  of  those  bodies,  consisting  either  of  miliary 
nodules  or  of  more  or  less  aggregated  masses,  which  are  usually  described 
as  tubercle  and  contain  the  "tubercle"  bacillus.  Although  it  is  true 
on  the  one  hand  that  there  is  no  absolute  histological  test  of  tuber- 
cular products,  the  presence  of  Koch's  bacillus  being  the  only  positive 
criterion,  and  on  the  other  that  the  bacillus  is  not  always  found  in  some 
cases  which  are  in  every  other  respect,  both  clinical  and  anatomical, 
identical  with  those  of  the  typical  tuberculosis,  yet  the  post-mortem  recog- 


TUBERCULOSIS.  I  4  5 

nition  of  tubercular  disease  is,  as  a  rule,  of  no  great  difficulty  ;  and,  where 
both  the  clinical  facts  and  the  post-mortem  appearances  of  any  given 
case  coincide  with  what  is  generally  known  as  tuberculosis,  the  non- 
discovery  of  the  bacillus  should  be  referred  rather  to  an  imperfect 
knowledge  of  all  its  conditions  than  to  a  mistaken  diagnosis. 

General  or  acute  tuberculosis  is  an  exceedingly  common  disease  in 
young  children.  It  may  occur  at  any  age,  though  but  seldom  in  infants 
under  three  months  old.  While  adhering  strongly  to  the  old  belief 
that,  whether  tuberculosis  is  directly  transmissible  by  inheritance  or 
not,  there  is  a  remarkable  proclivity  in  certain  families  to  this  disease 
in  at  least  its  pulmonary  form  after  early  childhood,  even  when  the 
members  of  such  families  have  lived  in  very  diverse  conditions ;  and 
while  recognising,  further/  that  there  is  a  very  frequent  history  of 
phthisis  or  other  tubercular  disease  in  the  families  of  young  children 
dying  from  acute  or  general  tuberculosis  of  various  forms,  I  must  yet 
emphatically  state  that  in  a  large  number  of  cases,  either  diagnosed  or 
proved  to  be  tubercular  in  infants  and  young  children,  which  have  come 
under  my  observation  there  was  no  reason,  as  far  as  the  history  went, 
to  suspect  the  occurrence  of  any  tubercular  disease  in  the  patients' 
immediate  families.  Indeed  from  the  clinical  side  only  the  features  of 
a  specific  disease  are  more  saliently  marked  in  general  tuberculosis  as 
occurring  in  young  children  than  in  almost  any  other  of  its  forms 
or  subjects.  Concerning  this  and  other  points  the  observations  and 
comments  of  Dr.  Sturges  are  of  great  value.1  He  took  consecutively 
from  the  post-mortem  records  of  the  Hospital  for  Sick  Children  1420 
cases  of  all  kinds,  of  which  more  than  30  per  cent,  were  deaths  from 
tubercle.  Analysis  of  these  showed  that  it  is  from  birth  up  to  five 
years  old  that  "tubercular  development  has  its  chief  activity  and  widest 
range,"  and  further,  with  due  allowance  made  for  the  imperfection  or 
absence  of  family  histories  in  many,  that  "inheritance  itself  fails  to 
account  for  the  enormous  frequency  of  infantile  tuberculosis."  With 
respect  to  204  cases  of  tubercular  deaths  trustworthy  family  records 
showed  that  both  parents  were  healthy  in  107  instances,  one  parent 
phthisical  in  44,  and  both  parents  phthisical  in  but  one. 

Besides  the  many  well-known  unhygienic  and  individual  conditions 
favourable  to  tubercular  development,  which  largely  account  for  the 
ravages  of  this  disease  among  the  children  of  the  working  classes  of  our 
large  towns,  the  frequent  and  close  association  of  measles  with  sequent 
tuberculosis  must  strike  all  who  are  widely  acquainted  with  disease  in 
children.  On  this  point  again  I  would  refer  to  the  writings  of  Dr. 
Sturges,  with  whose  experience  my  own  is  in  full  accord,  my  note-books 
containing  numerous  instances  of  tuberculosis  following  in  a  few  weeks 
1  See  Westminster  Hospital  Reports,  vol.  iv.,  Churchill,  18S8. 

K 


146  GENERAL  DISEASES. 

or  a  few  months  on  measles,  in  children  who  were  previously  in  perfect 
health.  "We  may  well  believe  that  not  only  measles  but  also  other 
diseases  which  are  not  seldom  followed  by  tuberculosis,  such  as  whooping- 
cough,  broncho-pneumonia,  and,  though  to  a  less  degree,  enteric  fever, 
may  prepare  the  soil  for  the  reception  and  growth  of  the  tubercle  bacillus 
by  injuring  the  structure  of  the  mucous  membranes. 

Into  the  general  question  of  the  many  ways  by  which  the  tubercle 
bacillus  may  find  its  way  into  the  body,  or  into  the  matter  of  prophy- 
laxis, I  cannot  enter  here,  but  would  insist,  in  passing  from  this  all- 
important  subject,  on  the  advisability  of  thoroughly  boiling  for  the  use 
of  young  children  all  milk  from  doubtful  sources  (which  is  tantamount 
to  recommending  this  practice  universally  to  the  poor),  and  of  spreading 
as  widely  as  possible  the  knowledge,  acquired  of  late,  concerning  the 
infective  nature  of  the  sputum  of  consumptive  persons.  Doubtless,  as 
we  have  seen  when  treating  of  scrofulosis,  there  is  an  intimate  connexion 
between  the  caseous  products  of  this  affection  and  both  localised  and 
general  tuberculosis.  Caseous  lymphatic  glands,  whether  tubercular  or 
not  from  the  outset,  are  frequently  the  starting-point  of  widely  distributed 
tubercle  ;  and  we  can  draw  no  hard  and  fast  line  between  those  cases  of 
"  strumous  "  or  "  tubercular  "  disease  of  bones  and  joints  which  remain 
localised,  and  those  which  are  followed  by  abdominal,  thoracic,  or  cerebral 
tuberculosis.  "We  may  certainly  assume  without  controversy  that  casea- 
tion of  any  part  or  organ,  from  whatever  cause  arising,  is  in  itself  a 
favourable  nidus  for  tubercular  development ;  and,  though  we  from  time 
to  time  meet  with  undoubted  cases  of  acute  miliary  tuberculosis  in  bodies 
absolutely  free  from  any  caseous  focus,  it  is  certain  that  in  a  large 
majority  of  instances  such  a  focus  is  found,  and  especially  often  in  the 
bronchial  or  abdominal  glands,  from  which  further  disease  has  clearly 
been  disseminated  in  the  lung  or  other  organs. 

Chronic  tuberculosis  in  children  is  usually,  in  its  clinical  aspect  at 
least,  of  either  the  predominantly  abdominal  or  pulmonary  form,  and  is 
dealt  with  under  these  headings,  although  there  is  a  class  of  cases  which 
cannot  be  called  acute,  lasting  as  they  do  for  many  weeks  or  months, 
where  general  symptoms,  such  as  wasting  and  anorexia,  often  endure  for 
a  considerable  time  with  but  little  and  sometimes  no  fever,  and  where, 
after  death,  caseous  and  not  miliary  tubercle  is  found  widely  dissemi- 
nated through  the  body.  For  the  most  part,  however,  miliary  tubercle 
occurs,  with  varying  degrees  of  caseous  degeneration,  in  cases  known  as 
general  tuberculosis,  and  these  are  described  as  acute  or  sub-acute  tuber- 
culosis. Miliary  tuberculosis  runs  the  acutest  course,  and  is  thus  liable 
to  be  mistaken  for  other  diseases.  "When  there  are  few  local  signs  or 
symptoms,  or  when  these  mainly  point  to  the  abdomen,  enteric  fever 
must  always  be  thought  of,  and  often  cannot  be  excluded  until  the  lapse 


TUBERCULOSIS.  1 47 

of  time  brings  differentiating  facte  to  light.  Should  the  main  stress 
of  the  disease  be  pulmonary  the  ease  may  closely  simulate  broncho- 
pneumonia, and  should  it  be  cerebral  we  may  have  to  hesitate  for  some 
time  before  definitely  deciding  on  the  nature  of  the  attack.  In  every 
case  of  suspected  tuberculosis  we  should  carefully  and  repeatedly  examine 
the  chest  for  pulmonary  or  pleuritic  signs,  explore  the  abdomen  for 
enlarged  glands,  and,  when  possible,  search  with  the  ophthalmoscope 
for  choroidal  tubercle  in  order  to  facilitate  our  diagnosis.  In  a  great 
majority  of  cases  there  is  a  history  of  more  or  less  marked  ill-health 
and  wasting  of  some  duration  before  the  clinical  outbreak  of  acute 
tuberculosis,  whether  such  outbreak  be  general  or  apparently  localised. 

So  insidious,  at  least  very  often,  and  slightly  characteristic  are  the 
early  symptoms  of  acute  tuberculosis  that  little  can  be  gained  by  an 
attempt  at  detailed  enumeration.  Loss  of  appetite,  wasting,  anaemia, 
some  oedema  of  the  feet,  remittent  pyrexia,  slight  though  it  be  at  first, 
and  general  irritability  are  a  group  of  phenomena  at  once  frequent  and 
full  of  warning  import,  but  unless  some  localising  signs  appear,  as  indeed 
they  usually  do  sooner  or  later,  either  in  chest,  abdomen  or  head,  our 
diagnosis  must  often  be  doubtful  until  near  the  end  or  until  after  the 
necropsy.  There  may  be  much  disease  of  the  lung  with  but  slight  signs 
or  only  those  of  localised  pleuritis,  and  very  little  or  no  cough ;  there 
may  be  abundant  intestinal  disease  without  diarrhoea ;  and  multiple 
caseous  tumours  in  the  brain,  or  even  miliary  tubercle,  with  no  local 
indications  in  paralysis  or  spasm,  and  no  clinical  or  post-mortem  evidence 
of  meningitis.  I  have  seen  several  cases  of  general  tuberculosis  beginning 
apparently  suddenly  with  severe  pain  in  the  abdomen,  and  both  with  and 
without  vomiting,  this  last  symptom,  when  present,  being  doubtless  due 
to  the  acute  peritonitis  found  post-mortem. 

I  have  often  seen  a  small  purpuric  eruption  develop,  more  especially 
in  the  feet  and  legs,  shortly  before  death  in  all  kinds  of  tuberculosis, 
and  considerable  oedema  of  the  feet  at  this  period  is  very  frequent. 

With  all  these  facts  in  view  it  is  clear  that  we  can  lay  down  no 
diagnostic  rules  for  all  cases,  and  that  consequently,  though  prognosis 
must  always  be  grave,  it  should  never  be  hopeless  in  the  early  stages 
of  suspected  tuberculosis.  It  is  not  very  uncommon  to  meet  with  cases 
where  much  wasting,  fever,  cerebral  symptoms,  vomiting,  diarrhoea,  or 
even  a  prolonged  condition  of  deeply  defective  consciousness  may,  any 
or  all  of  them,  be  present  and  endure  for  weeks,  to  be  followed  by  gradual 
or  rapid  restoration  to  perfect  health.  Whether  such  cases  be  tubercular 
or  not  I  am  inclined  to  lay  it  down  as  a  general  rule,  that  where  acute 
tubercular  disease  is  deliberately  diagnosed  by  an  experienced  physician, 
and  the  patient  ultimately  recovers,  the  case  is  one  which  points  to  or 
simulates  the  cerebral  form  of  tuberculosis.     That  tubercle  may  become 


148  GENERAL  DISEASES. 

obsolete  in  any  of  its  haunts  has  been  proved  by  post-mortem  observation, 
and  I  have  myself  seen  cases  which  show  that  even  a  localised  menin- 
gitis of  tubercular  origin  may  recover.  Tubercular  peritonitis,  whether 
ultimately  followed  by  renewed  or  further  tubercular  development  or 
not,  unquestionably  recovers  with  no  great  rarity,  but  in  these  cases  its 
onset  is  mainly  insidious  and  its  course  chronic.  When  acute  tuber- 
culosis, giving  rise  to  marked  signs  of  bronchitis,  attacks  the  lungs,  its 
event  is  always  fatal ;  and  the  same  may,  I  think,  be  said  of  tubercular 
disease,  whether  ulcerative  or  not,  of  the  intestinal  mucosa. 

Of  the  treatment  of  acute  tuberculosis  generally  but  little  can  be  said 
in  a  practical  clinical  work,  for  the  question  is  mainly  one  of  preven- 
tive medicine.  In  the  early  stage  of  all  cases  of  suspected  tuberculosis 
of  whatever  form  I  am  in  the  habit,  following  Sturges,  of  giving  the 
hypophosphite  of  soda  or  lime  in  full  doses, — 10  grains  three  times  a 
day  to  an  infant  of  a  year  old.  This  practice  is  wholly  empirical,  but 
being  sometimes  coincident  with  recovery  is  perhaps  something  more 
than  harmless.  In  the  later  stages,  or  when  the  disease  is  apparently 
established,  little  can  be  expected,  according  to  my  own  experience, 
but  the  partial  relief,  in  various  ways,  of  some  of  the  suffering.  An 
interesting  and  important  series  of  cases,  however,  carefully  detailed 
by  Dr.  Sturges  in  vol.  i.  of  the  Westminster  Hospital  Eeports  1885, 
showing  recovery  in  several  instances  of  what  was  to  all  clinical  appear- 
ance advanced  tuberculosis,  both  meningeal  and  peritoneal,  coincidently 
with  the  administration  of  the  hypophosphite  of  soda,  deserves  the 
closest  attention  Dr.  Sturges'  comments  are  marked  by  the  strictest 
logical  acumen,  and  his  advice  to  try  large  doses  of  the  drug  in  all  such 
cases,  as  well  as  in  the  early  periods,  may  be  followed  always  with  safety 
and  sometimes  with  hope. 

The  treatment  of  the  chronic  expressions  of  tuberculosis  is  dealt  with 
in  connexion  with  their  special  forms. 


CHAPTER  V. 

ON   ANAEMIA,    PURPURA    AND   SCURVY. 

Anaemia. 

Pallor  of  the  skin  and  mucous  membranes  in  association  with  deficiency 
of  haemoglobin,  with  or  without  numerical  diminution  of  the  red  blood- 
corpuscles,  is  very  prominent  in  many  of  the  nutritive  disorders  of  child- 
hood both  acute  and  chronic,  and  is  brought  about  with  great  readiness. 


ANAEMIA,  PURPURA  AND  SCURVY.  I  49 

Familiar  examples  of  profound  anaemia  are  seen  in  cases  of  chronic 
diarrhoea,  nephritis,  valvular  heart-disease,  tuberculosis,  rickets,  syphilis, 
rheumatism  and  malaria,  and  the  seemingly  special  form  of  so-called 
"  splenic  anaemia,"  which  I  have  already  described  in  connexion  with 
enlargement  of  the  spleen,  is  almost  exclusively  an  affection  of  child- 
hood. Of  Hodgkin's  disease  too,  described  as  lymphadenoma,  malignant 
lymphoma  and  otherwise,  which  is  characterized  by  a  widespread  en- 
largement of  the  lymphatic  glands  and  by  lymphatic  growth  in  other 
tissues  with  marked  and  progressive  anaemia  and  wasting,  many  instances 
are  found  in  later  childhood  and  youth.  I  have  seen  several  under  the 
age  of  puberty,  and  some  have  been  recorded  in  the  first  year  of  life. 
Anaemia  resulting  from  metallic  poisons,  such  as  lead  or  mercury,  and 
from  the  presence  of  intestinal  or  other  parasites  such  as  Anchylostoma, 
Filaria,  or  Bilharzia,  need  only  be  mentioned  as  necessary  to  be  borne  in 
mind,  though  mostly  of  very  exceptional  occurrence  in  English  practice. 

The  variety  of  anaemia  known  as  leueocythcemia  or  leuhcemia,  marked 
by  great  positive  increase  of  the  number  of  white  blood-corpuscles, 
diminution  of  that  of  the  red,  and  overgrowth  of  the  spleen  and 
often  of  the  bone- marrow,  has  been  previously  alluded  to.  Although 
undoubtedly  occurring  in  childhood  and  occasionally  in  early  infancy, 
either  in  connexion  with  various  and  general  disorders  of  nutrition  or 
in  apparent  independence  of  such  affections,  this  disease  is,  in  my  ex- 
perience, rare  before  adult  or  middle  age,  and,  important  though  it 
is  from  its  prevailing  fatality  and  its  haemorrhagic  incidents,  needs  no 
special  consideration  here.  It  is  probable  that  several  cases  reported  as 
leucocythaemia  in  infants  and  young  children  should  be  classed  rather 
with  the  "  splenic  "  anaemias  already  described. 

Besides  the  above-mentioned  secondary  or  more  or  less  specialised 
forms  of  this  blood  affection  we  meet  with  instances  where  simple 
anaemia  obtains  in  various  degrees  in  all  the  same  circumstances  as  in 
adults,  and  sometimes  with  no  ascertainable  exciting  cause  and  unmarked 
by  any  concomitant  sign  of  organic  disease.  There  are  examples,  in  fact, 
as  well  in  childhood  as  in  later  life,  both  of  the  apparently  idiopathic 
anaemia  or  even  chlorosis  which  recovers  and,  though  this  is  certainly 
rare,  of  the  pernicious  anaemia  which  tends  to  death.  Anaemia  of  more 
or  less  sudden  onset,  following  on  fright,  or  accompanying  other  nervous 
disorders,  must  be  recognised  in  children  as  well  as  in  adults.  I  have 
seen  several  instances  of  this  in  various  degrees,  and  some  pronounced 
examples  have  been  recorded  by  Gull  and  others. 

The  subjects  of  marked  anaemia  are  usually  languid  and  fretful  with 
bad  appetite,  imperfect  digestion,  frequent  headache  and  a  tendency  to 
constipation  often  alternating  with  attacks  of  diarrhoea,  (Edema  of  the 
extremities  is  common,  short  breathing  is  sometimes  marked,  and  the 


15  O  GENERAL  DISEASES. 

murmurs  over  the  praecordia  and  in  the  neck,  so  familiar  to  us  in  adult 
cases  of  anaemia,  are  often  heard.  It  is  unnecessary  to  enter  here  into 
any  discussion  on  the  differentiation  of  anaemias  by  estimating  the  vary- 
ing proportions  of  red  corpuscles  and  haemoglobin,  for  such  cases  as  we 
are  considering  are,  although  less  common,  quite  the  same  as  those  we 
meet  with  in  adults ;  but  it  may  be  said  that,  as  a  rule,  the  less  diminu- 
tion there  is  in  the  number  of  the  red  corpuscles,  however  deficient  the 
haemoglobin  may  be  (as  appears  to  be  usually  the  case  in  so-called 
chlorosis)  the  more  favourable  is  the  forecast,  and  the  greater  the  hope 
from  appropriate  treatment. 

It  should  be  remembered  that  the  normal  blood  in  early  childhood 
is  richer  in  leucocytes,  poorer  in  haemoglobin,  and  of  lower  specific 
gravity  than  in  later  life.  In  it  are  found  also  in  some  degree  the 
nucleated  red  corpuscles  which  in  adults  are  only  seen  in  anaemic  states.1 
These  and  other  differences,  pointing  to  a  less  stable  condition  and  readier 
depravation  of  the  blood  in  young  children,  may  perhaps  explain  in  some 
degree  the  often  rapid  onset  and  progress  of  infantile  anaemia  in  many 
various  circumstances,  and  its  frequent  occurrence  as  a  sequel  of  ap- 
parently slight  or  indefinite  causes. 

On  the  whole  it  may  be  said  that  the  nutritive  failure  in  infancy 
and  early  childhood  so  commonly  resulting  from  numerous  diseases  and 
disorders,  or  from  hygienic  and  dietetic  errors,  is  especially  often  pro- 
ductive of  prominent  anaemia,  which  in  adults  has  a  more  limited 
clinical  aetiology. 

The  treatment  of  anaemia  of  course  depends  largely  on  whatever 
ascertainable  condition  may  be  found  to  underlie  the  symptoms,  and 
all  therapeutical  indications  offered  by  the  history  or  evidence  of  ante- 
cedent or  more  widespread  disease  must  be  sought  for  and  duly  attended 
to.  In  all  it  is  imperative  to  take  every  trouble  to  establish  an  ample 
and  easily  digestible  dietary  and  to  avoid  monotony  in  the  meals,  and  it 
will  be  well  in  some  to  seek  to  improve  the  appetite  by  the  occasional 
administration  of  a  drop  or  two  of  dilute  hydrochloric  acid,  with  or  with- 
out tincture  of  nux  vomica,  in  some  aromatic  water.  Equally  important 
are  the  preservation  of  the  body  warmth,  and  an  ample  supply  of  fresh 
air  and  sunlight.  Close  confinement  and  darkness  will  soon  blight  young- 
children  and  mark  them  with  an  anaemia  which  admits  of  even  less  doubt 
as  to  its  causation  than  the  examples  so  familiar  to  us  among  girls  of  the 
working  classes.  We  must  therefore  give  clue  care  to  the  ventilation  of 
rooms  by  night  as  well  as  by  day.  In  bad  cases  there  is  cardiac  weak- 
ness and  sometimes  cardiac  dilatation  as  a  part  of  the  general  condition. 
Rest,  therefore,  should  always  be  enjoined  when  exercise  causes  fatigue, 

1  See  Dr.  C.  Griffith's  article  on  "  Diseases  of  the  Blood  "  in  vol.  iii.  of  Keating's 
Cyclopaedia  of  Diseases  of  Children. 


AN.EMIA,  PURPURA  AND  SCURVY.  I  5  I 

especially  if  there  be  any  tendency  to  breathlessness  or  oedema.  In  such 
cases  children  should  not  he  allowed  to  walk  when  taken  out  of  doors. 

Constipation  should  he  relieved  by  occasional  purgatives  such  as 
aloes,  senna,  or  sulphur  when  dietetic  and  other  measures  fail.  Daily 
tepid  baths,  however,  with  subsequent  rubbing  of  the  chest  and  body, 
and  kneading  of  the  abdomen  will  often  relieve  this  symptom  while 
improving  the  general  condition. 

As  regards  medicines  I  believe  none  are  better,  when  not  otherwise 
contra-indicated,  than  cod-liver  oil,  arsenic  and  iron.  In  some  cases 
all  of  these  may  be  given  with  advantage.  Rapid  improvement  has 
more  often  seemed  to  me  to  follow  on  the  use  of  the  two  former,  either 
singly  or  in  combination,  than  on  that  of  the  latter  alone.  Cod-liver  oil 
is  especially  useful  in  the  case  of  thin  and  puny  children  with  capricious 
appetites,  who  frequently  take  it  better  than  anything  else.  The  value 
of  arsenic  in  anaemia  generally  appears  to  be  as  unquestionable  as  that 
of  any  drug  in  any  disease.  From  half  a  minim  to  two  minims  of 
Fowler's  solution  three  times  a  day  appears  to  be  a  sufficient  dose  for 
children  from  one  year  old  and  upwards.  I  have  several  times  seen 
untoward  symptoms,  such  as  sore  eyes  and  sickness,  arise  when  larger 
doses  have  been  given,  and  am  of  opinion  after  a  large  experience  of 
this  drug  in  patients  of  all  ages  that,  although  adults  can  well  take 
considerably  more  than  the  official  doses  for  an  indefinite  period,  there  is 
no  disproportionate  tolerance  of  the  drug  in  early  life. 

The  preparation  of  iron  that  I  usually  give  to  anaemic  children, 
whether  alone  or  in  combination  Avith  the  liquor  arsenicalis,  is  either 
the  tartrate  or  ammonio-citrate  in  doses  of  from  one  to  five  grains 
according  to  age. 

Puppupa. 

In  considering  the  clinical  aspects  of  purpura  as  an  affection  of  child- 
hood I  must  confine  myself  mainly  to  those  cases  where  extravasations  of 
blood  into  the  skin,  mucous  membranes,  internal  organs,  or  joints  occur 
with  more  or  less  apparent  independence  of  other  distinct  morbid  pro- 
cesses. In  children  as  well  as  in  adults  haemorrhages  of  this  kind,  but 
especially  those  into  the  skin,  are  apt  to  take  place  in  various  blood  con- 
ditions such  as  the  exanthemata,  septic  endocarditis,  syphilis,  kidney- 
disease,  heart-disease,  anaemia,  leucocythaemia,  scurvy  (especially  in  the 
complex  of  symptoms  often  described  as  "  scurvy  -rickets "),  and  many 
other  cachexia?,  among  which  may  be  mentioned  the  state  of  low  vitality 
caused  by  prolonged  acute  illness,  as,  for  instance,  enteric  fever,  after  which 
a  purpuric  eruption,  chiefly  on  the  legs,  is  apt  to  appear  when  the  patient 
begins  to  walk  about.     Purpura  may  also  be  the  result  of  the  administra- 


152  GENERAL  DISEASES. 

tion  of  certain  drugs,  among  which  iodide  of  potassium  is  prominent.  In 
a  not  uncommon  class  of  cases,  probably  peculiar  to  childhood  and  else- 
where referred  to,  where  there  is  profound  anaemia  with  enlarged  spleen 
often  unconnected  with  either  rickets  or  syphilis,  I  have  several  times 
observed  both  cutaneous  and  mucous  haemorrhages,  and  in  this  as  in  other 
purpuric  conditions  there  may  be  extravasation  into  the  structures  of  the 
fundus  of  the  eye. 

Of  the  ultimate  causation  of  purpura  and  the  nature  of  the  part  played 
by  changes  in  the  blood  or  vessels  or  by  the  vaso-motor  or  trophic  nervous 
system,  or  of  the  question  of  septic  origin,  it  is  unnecessary  to  speak,  for 
our  knowledge  here  is  very  uncertain  and  therefore  but  little  helpful  at 
present  to  practical  clinical  study. 

In  children  the  hereditary  affection  known  as  licemophilia,  or  the 
"  haemorrhagic  diathesis"  or  "bleeder's  disease,"  is  a  recognised  cause  of 
haemorrhages  into  skin,  mucous  membranes  and  joints,  whether  appearing 
spontaneously  or  as  the  result  of  injuries.  This  morbid  tendency  is 
usually  manifested  early,  though  rarely  in  infancy,  lasts  through  life,  and 
generally  leads  to  death  in  childhood  or  before  mature  age.  In  its  typical 
form  the  disease  is  rare,  and  for  its  detailed  description  I  would  refer  to 
the  text-books.  There  may  be  bleeding  from  the  nose  or  mouth,  haemat- 
emesis,  melaena  or  haematuria;  excitement,  headache,  feverishness,  or 
other  symptoms  of  illness  may  be  present  in  the  attacks ;  and  occasionally 
there  are  convulsions. 

In  considering  purpura  as  an  apparently  independent  affection  we  are 
at  once  struck  with  the  existence  of  a  class  of  cases  which,  but  from  their 
non-hereditary  character  and  the  absence  in  many  instances  of  a  tendency 
to  recurrence,  are  indistinguishable  from  so-called  true  haemophilia.  In 
some  which  are  recurrent  the  likeness  approaches  to  identity.  Some  of 
these  cases  begin  suddenly  in  the  midst  of  seemingly  good  health,  and 
may  or  may  not  be  ushered  in  or  subsequently  attended  by  some  pyrexia, 
headache,  irritability  or  other  symptoms.  In  some,  too,  besides  the  spon- 
taneous haemorrhages,  there  is  a  tendency  to  bleed  or  bruise  on  any  slight 
injury.  When  we  reflect  on  the  close  similarity  of  these  two  sets  of  cases, 
and,  further,  on  the  numerous  general  causes  of  secondary  purpura  above 
referred  to,  and  remember  the  tendency  to  prolonged  haemorrhage  in  leuco- 
cythaemia  after  the  extraction  of  a  tooth  or  the  application  of  leeches, 
it  is  difficult  to  draw  a  hard  and  fast  line  between  primary  and  secondary 
purpura,  or  to  reject  the  conclusion  that  in  some  at  least  of  the  non- 
hereditary  cases  the  pathology  is  similar  to  that  of  "haemophilia."  My 
experience,  moreover,  forbids  me  to  make  a  material  distinction  between 
"  purpura  simplex,"  a  term  usually  applied  to  haemorrhages  limited  to  the 
skin,  and  "  purpura  haemorrhagica  "  which  includes  bleeding  from  mucous 
membranes.     The  first  of  these  forms  often  passes  into  or  accompanies 


ANJEMIA,  PURPURA  AND  SCURVY.  153 

the  second,  and  Loth  may  he  transient,  recurrent,  or  fatal,  apparently 
idiopathic,  or  clearly  secondary. 

Purpura  of  the  skin  only,  as  far  as  can  he  ohserved  in  life,  consisting 
in  small  circular  or  more  extensive  extravasations  soon  taking  on  a  bruise- 
like  appearance,  is  not  uncommon,  and  often  passes  off  in  a  few  weeks  or 
less,  without  recurrence,  after  rest  in  bed  and  appropriate  nutritive  and 
tonic  treatment.  Such  cases  are  known  as  simple  purpura.  In  my  ex- 
perience this  condition,  though  most  often  justifying  a  good  prognosis, 
rarely  occurs  in  children  even  apparently  healthy,  hut  rather  is  symptom- 
atic of  had  nutrition  or  previous  disease.  It  is  unaccompanied,  as  a  rule, 
by  any  febrile  disturbance.  Fresh  crops  of  spots  or  patches  may  occur  for 
an  indefinite  time  if  the  patient  be  neglected  or  allowed  to  get  up.  But 
what  seems  to  be  this  form  of  purpura  in  cases  which  die  from  underlying 
conditions  is  sometimes  found  post-mortem  to  be  "  haemorrhagic"  as  well, 
and  to  extend  to  internal  organs.  In  the  case  of  an  anaemic  and  probably 
syphilitic  child,  with  a  small  and  not  very  extensive  purpuric  eruption 
during  life,  I  found  post-mortem  numerous  haemorrhages  in  the  subcuta- 
neous tissue,  the  pleura  and  the  kidneys ;  and  in  another,  which  died  with 
signs  of  broncho-pneumonia,  diarrhoea  and  vomiting,  many  extravasations 
were  discovered  in  the  liver,  the  lungs,  and  the  ileum  besides  the  cutaneous 
purpura  which  alone  was  seen  before  death.  There  is,  further,  a  class  of 
cases  described  by  Henoch  and  others  under  the  name  of  "purpura  ful- 
minans"  which  are  marked  by  large  and  rapidly  spreading  cutaneous 
extravasations  only,  without  fever,  and  end  hi  death  after  a  few  days' 
course.  One  such  case  I  saw  in  a  boy  of  nine,  beginning  six  weeks  after 
the  onset  of  scarlatina.  The  post-mortem  examination  revealed  nothing 
but  general  anaemia  of  internal  organs.  Of  the  few  cases  of  this  latter 
kind  hitherto  reported  some  followed  acute  disease,  such  as  pneumonia, 
hut  others  were  to  all  appearance  independent. 

So-called  simple  purpura  is  sometimes  accompanied  by  pain  and 
tenderness  in  the  limbs  and  joints,  and  occasionally  by  articular  swell- 
ing or  oedema  of  the  feet,  hands  or  eyelids.  Erythema  nodosum  may 
also  concur,  as  also  more  or  less  bullous  eruption.  Such  cases  are  often 
called  "  purpura  rheumatica,"  but  are  rarely  marked  by  the  clinical  signs 
of  true  rheumatism.  The  joint  swellings  are  certainly  sometimes,  and 
perhaps  most  often,  haemorrhagic  in  nature. 

Among  the  cases  known  as  "  purpura  haemorrhagica,"  which  are 
marked  by  mucous  haemorrhages  or  joint-affection  as  well  as  by  fre- 
quently extensive  cutaneous  purpura,  and  are  seemingly  idiopathic  or 
at  least  not  seldom  occur  in  children  of  apparently  good  health,  some 
fever  and  constitutional  symptoms  are  not  rare  either  as  heralding 
or  accompanying  the  special  symptoms.  In  some  instances  there  is 
abdominal  pain  and   tenderness   with  vomiting,   profuse   melaena   and 


154  GENERAL  DISEASES. 

hsematemesis,  and  frequent  swelling  of  joints.  Some  are  gradual  in 
onset  and  frequently  recurrent,  with  healthy  intervals  of  months  or  even 
more  than  a  year,  and  may  occasionally  end  fatally  from  haemorrhage 
either  into  the  brain  or  from  mucous  surfaces,  or  with  gradually  in- 
creasing anaemia.  Other,  and  perhaps  the  more  numerous,  cases  begin 
suddenly,  and,  though  marked  by  profuse  epistaxis  and  bleeding  from 
the  gums  and  other  parts  of  the  mouth,  with  sometimes  considerable 
melaena,  haematemesis,  haemoptysis  or  haematuria,  recover  completely 
without  fever  in  a  week  or  two  from  the  onset.  In  many  cases  of 
purpura,  and  especially  in  those  connected  with  mucous  haemorrhages, 
the  large  bruise-like  patches  or  ecchymoses  which  are  seen  appear  first 
as  such,  and  are  the  result  of  bleeding  into  the  deeper  tissues.  They 
are  often  characterized  by  more  or  less  swelling. 

I  select  the  following  cases  from  my  note-books  in  illustration  of  my 
remarks  : — 

(i.)  A  boy  of  10,  with  a  very  good  personal  and  family  history  and 
previously  well  dieted  in  every  particular,  had  one  week  before  admis- 
sion a  painful  swelling  of  the  right  elbow,  followed  the  same  day  by  a 
purpuric  eruption  on  arms  and  legs.  Two  days  afterwards  he  vomited 
blood,  was  very  drowsy,  and  three  days  later  had  great  pain  in  his 
abdomen  and  passed  much  blood  from  the  rectum.  These  bleedings 
recurred  a  few  times,  but  the  boy  quite  recovered  in  a  fortnight. 

(2.)  A  boy  of  3^  was  admitted  with  extensive  cutaneous  purpura, 
epistaxis,  bleeding  from  the  mouth  and  melaena,  with  a  history  of  a 
similar  attack,  about  a  year  and  a  half  before,  during  whooping  cough, 
and  a  subsequent  tendency  to  bruise  severely  after  any  slight  knock  or 
injury.  After  a  few  days  there  was  much  bleeding  from  under  the 
thumb-nail,  which  lasted  several  days  and  was  difficult  to  arrest ;  the 
nail  separated,  and  a  slough  came  away  from  the  dorsum  of  the  thumb. 
But  for  the  absence  of  any  hereditary  history  this  case  might  be  regarded 
as  one  of  haemophilia. 

(3.)  A  boy  of  10,  with  good  personal  and  family  history,  was  admitted 
with  profuse  purpura,  consisting  of  small  spots  and  large  bruise-like 
patches  all  over  the  body  except  the  face,  and  with  sanguineous  bullae  on 
the  lips  of  a  few  days'  duration.  He  had  an  exactly  similar  attack  one 
year  previously.  Both  attacks  lasted  three  months,  and  both  began  with 
oral  haemorrhage  and  purpura  on  the  legs.  During  the  second  attack 
he  was  kept  in  bed  and  had  several  slight  rises  of  temperature.  There 
was  never  any  epistaxis  or  undue  tendency  to  bleed  or  bruise  from 
traumatism. 

(4.)  A  girl  of  12,  with  rheumatic  parents,  who  was  very  anaemic, 
always  delicate  and  had  signs  of  past  rickets,  suffered  from  a  purpuric 
eruption,  chiefly  confined  to  the  legs,  and  pain,  but  no  swelling,  in  her 


AN/EMIA,  PURPURA  AND  SCURVY.  I  5  5 

ankles  with  each  .successive  crop  of  spots.  During  her  stay  of  three 
months  she  had  several  attacks  of  hematuria.  (Edema  of  the  legs  had 
preceded  this  affection  for  two  months.  She  had  no  fever  nor  any 
other  sign  of  rheumatism.  Recovery  was  complete,  and  the  general 
health  and  appearance  much  improved,  when  she  left  hospital. 

(5.)  A  girl  of  7,  with  good  family  history,  was  admitted  after  suffering 
for  ten  days  with  epigastric  pain,  headache,  and  green  vomiting.  Me- 
lena  soon  set  in,  and  two  days  after  admission  she  passed  blood  thirteen 
times  and  had  a  severe  general  convulsive  attack  for  half  an  hour, 
followed  by  coma  for  six  hours.  The  temperature  rose  to  1040,  large 
Mood  extravasations  appeared  on  the  buttocks  and  eyelids,  and  there- 
was  some  bleeding  from  the  lips.  She  improved  after  a  week  and 
went  out  well  in  a  month.  Two  quite  similar  attacks  without  convul- 
sions had  occurred  at  the  age  of  4  and  $h  respectively.  In  connexion 
with  this  case  I  would  mention  another  in  which  there  was  right-sided 
hemiplegia  with  rigidity,  afterwards  recovering,  during  an  attack  of 
what  seemed  to  be  exclusively  "  simple  "  purpura. 

As  regards  prognosis  it  must  be  acknowledged  that,  while  we  remain 
in  ignorance  of  the  pathological  changes  and  events  underlying  the 
frequent  cases  of  purpura  of  all  kinds  which  are  seemingly  neither  here- 
ditary nor  connected  with  any  other  demonstrable  disorder,  it  is  well  to 
be  very  cautious  in  pronouncing  our  opinion.  Doubtless  a  very  large 
majority  of  all  cases  recover,  excluding  those  known  as  typical  "  haemo- 
philia "  and  the  rare  instances  of  "  purpura  fulminans  "  which  are  marked, 
as  we  have  seen,  by  sudden  and  large  subcutaneous  haemorrhages ;  hut 
we  have  no  definite  ground  for  prophesying  non- recurrence  in  any.  It 
would  appear  that  the  apparently  simple  purpura  following  on  reme- 
diable cachexias,  and  ordinary  hemorrhagic  purpura,  especially  when 
mainly  evidenced  by  epistaxis  and  bleeding  from  the  mouth,  and  be- 
ginning acutely  in  a  state  of  seeming  health,  eminently  justify  a  good 
prognosis ;  and  my  own  experience  agrees  with  that  of  Henoch  in  show- 
ing that  recovery  may  almost  always  be  expected,  though  it  should  not 
be  foretold  prematurely,  in  those  apparently  grave  cases  which  are  marked 
by  abdominal  pain,  hematemesis  and  melena  even  of  great  extent. 
Purpuric  eruption  with  renal  dropsy  is  probably  almost  always  of  the 
gravest  augury. 

In  the  treatment  of  purpura  the  first  necessities  are  to  keep  the 
patient  in  bed  however  slight  the  attack  may  be,  and  to  use  appropriate 
remedies  for  any  discoverable  or  hypothetical  causal  conditions,  such 
as  rickets,  scurvy,  anaemia,  heart-disease,  or  septicaemia  in  any  of  its 
numerous  forms,  whether  nosologically  specified  or  not.  I  should  be 
inclined  in  most  instances  to  give  arsenic  and  some  preparation  of  iron, 
and  quinine  and  sulphuric  acid  are  sometimes  useful.     In  cases  where 


I  5  6  GENERAL  DISEASES. 

there  is  constipation,  and  others  which  do  not  soon  improve  by  rest  in 
bed,  purgative  treatment  may  be  tried  for  a  short  time,  as  strongly 
recommended  by  Eustace  Smith.  In  definite  haemophilia,  however,  and 
other  cases  beginning  acutely  without  precedent  anaemia  or  other  general 
disturbance,  complete  rest  and  symptomatic  treatment  to  check  haemor- 
rhage are  all  that  is  indicated.  The  liquid  extract  of  ergot  may  be 
tried  for  a  while  but  is  probably  of  little  use;  nor  does  hamamelis, 
in  my  opinion,  deserve  the  reputation  it  possesses  in  some  quarters. 
Profuse  epistaxis  must  be  arrested  by  plugging  the  nares,  external 
haemorrhage  by  the  application  of  the  perchloride  of  iron  or  some  other 
astringent  with  pressure,  haematemesis  by  ice  and  perhaps  small  doses 
of  opium,  and  melaena  by  injections  of  starch  and  opium  or  of  per- 
chloride or  pernitrate  of  iron  of  the  strength  of  one  drachm  or  half  a 
drachm  to  the  ounce  of  water  respectively. 

The  diet  in  all  cases  should  be  regulated  according  to  individual 
indications,  chronic  cases  with  anaemia  requiring  the  best  and  varied 
nourishment,  and  acute  cases  being  often  advantageously  fed  on  milk 
alone  for  awhile. 

Scurvy. 

I  have  already  incidentally  alluded  to  the  subject  of  scorbutus  in 
infants  under  the  headings  of  infantile  wasting  and  of  rickets.  From 
the  reports  of  many  cases  by  Drs.  Cheadle,  Barlow  and  others  it  can 
scarcely  be  doubted  that  there  is  an  association  between  the  occurrence 
of  haemorrhagic  symptoms  in  infants,  shown  especially  by  sub-periosteal 
haemorrhages  in  the  thighs,  bleeding  gums,  and  sometimes  by  cutaneous 
and  other  extravasations,  and  a  diet  markedly  deficient  in  fresh  animal 
and  vegetable  food.  These  cases,  as  we  have  seen,  are  usually  rickety  and, 
before  the  theory  of  scorbutus  was  put  forward,  were  often  described  as 
acute  rickets ;  while  those  where  the  most  prominent  or  only  symptoms 
were  swelling  of  the  limbs  with  tenderness,  owing  to  sub-periosteal  bleed- 
ing, were  previously  known  as  "haemorrhagic  periostitis."  Whatever 
be  the  true  pathology  of  this  class  of  cases,  and  whether  or  no  they  be 
rightly  regarded  as  all  of  one  class,  it  seems  clear  that  sub-periosteal 
haemorrhages  occurring  for  the  most  part  in  rickety  children  with  or 
without  bleeding  gums  or  extravasation  elsewhere,  and  with  or  with- 
out fever,  are  more  common  in  England  than  in  most  other  countries 
where  they  have  been  looked  for ;  and  that  in  many  instances,  where 
a  marked  absence  of  fresh  food  from  the  dietary  has  been  noted,  the 
symptoms  have  rapidly  improved  when  fresh  food  and  lemon-juice  have 
been  given.  It  must,  however,  be  borne  in  mind  that  in  a  considerable 
number  of  cases  of  so-called  acute-  or  scurvy-rickets  there  has   been 


AN.EMIA,  PURPURA  AND  SCURVY.  157 

nothing  else  to  mark  the  case  than  much  tenderness  and  swelling  of 
the  limbs  presumably  or  demonstrably  due  to  sub-periosteal  haemorrhage, 
and  that  at  least  in  some  of  them,  as  I  can  myself  testify,  the  diet  has 
certainly  been  in  no  case  lacking  in  antiscorbutic  elements.  On  the 
other  hand  spongy  and  bleeding  gums  or,  in  young  infants,  ulcerative 
stomatitis,  sometimes  associated  with  purpura,  are  from  time  to  time 
observed  in  cases  where  the  diet  has  been  singularly  deficient  in  these 
elements.  While,  therefore,  the  contention  that  so-called  "  acute  rickets  " 
always  implies  scorbutus  seems  not  to  be  established,  and  there  is  a 
probability  that  much  tenderness  and  swelling  of  the  limbs  in  rickets, 
and  even  sub-periosteal  haemorrhage,  may  be  referable  to  other  causes 
and  perhaps  to  the  malnutrition  of  rickets  alone,  we  may  on  the  other 
hand  regard  certain  cases  of  bleeding  gums,  with  or  without  extravasa- 
tions into  the  skin  or  elsewhere,  as  in  all  likelihood  of  scorbutic  origin 
when  the  nature  of  the  diet  is  favourable  to  such  disease.  No  one  need 
question  the  self-evident  proposition  that  in  all  cases  of  infantile  scurvy 
the  diet  is  deficient  in  some  necessary  material,  but  the  diagnostic 
difficulty  lies  in  the  question  as  to  what  cases  we  are  to  call  scurvy. 

I  have  already  alluded  to  the  contention  of  some  that  boiled  or 
otherwise  sterilised  milk  is  deficient  in  antiscorbutic  qualities,  and  have 
brought  clinical  evidence  to  show  that  this  statement,  at  least  without 
qualification,  is  incorrect.  "Whether  or  not  milk  which  has  been  sub- 
jected to  prolonged  or  repeated  boiling  or  steaming,  and  preserved  for  an 
indefinite  time  before  use,  is  antiscorbutic  may  perhaps  be  doubted  ;  and, 
in  view  both  of  the  very  scanty  clinical  evidence  available  on  this  point 
and  of  our  yet  imperfect  knowledge  of  the  possible  changes  induced  by 
these  processes,  it  would  seem  on  the  whole  advisable  to  boil  or  sterilise 
the  daily  supply  of  milk  and  use  it  at  once,  according  to  a  practice  which 
has  been  amply  proved  to  be  unobjectionable. 

In  all  cases  of  suspected  or  established  scorbutus  in  infants  appro- 
priate treatment  should  be  at  once  instituted.  All  preserved  foods 
should  be  abolished,  and  the  child  fed  on  fresh  milk  thickened  or  not 
with  potato-flour,  or  with  raw  meat-juice,  according  to  age.  A  few 
drachms  of  lemon-juice  should  also  be  given  daily  in  bad  cases. 


SECTION   III. 
ACUTE   FEBRILE   DISEASES. 


SECTION  III.— ACUTE  FEBRILE  DISEASES. 

In  this  section  I  include  diseases  marked  prominently  by  fever  and 
general  symptoms  whether  of  demonstrably  specific  origin  or  not.  In 
deference  to  long-established  custom  pneumonia,  more  properly  ranking 
here,  is  dealt  with  in  the  section  of  diseases  of  the  respiratory  system. 


CHAPTEK    I. 
PYREXIA. 

Rise  of  temperature  in  infants  and  young  children  is  of  much  more 
various  significance  than  in  later  years,  and  occasions  more  frequent 
diagnostic  difficulty.  At  the  same  time  it  is  very  often  of  far  slighter 
import.  The  cause  of  these  peculiarities  doubtless  lies  mainly  in  the 
greater  instability  of  the  higher  nervous  apparatus  which  numbers 
amongst  its  functions  the  regidation  of  the  body  temperature.  The 
nervous  factor  in  pyrexia  is  thus  especially  well  exemplified  in  children, 
and  we  find  both  increased  production  and  increased  loss  of  heat  as  the 
result  of  comparatively  slight  causes.  The  normal  temperature  of  a 
child  in  the  first  few  months  of  life  is  always  subject  to  more  marked 
fluctuations  than  in  the  adidt,  frequently  falling  some  degrees  below 
98°  F.  without  apparent  cause.  In  cases  of  markedly  bad  nutrition,  and 
especially  of  diarrhoea  and  vomiting,  the  drop  may  amount  even  to  ten 
degrees  from  time  to  time,  and  there  may  be  for  several  days  a  tempera- 
ture of  three  or  four  degrees  below  the  normal.  A  persistently  or 
remittently  subnormal  temperature  is  almost  the  rule  in  cases  of  rapid 
convalescence  from  enteric  fever  and  other  less  definite  febrile  conditions, 
especially  when  there  has  been  much  wasting,  but  this  is  to  some  extent 
common  in  adults  also.  It  may  be  due,  as  I  have  thought,  in  the  light 
of  a  theory  propounded  long  ago  by  Dr.  Ord,  to  a  lessened  production  of 
heat  as  such  during  the  process  of  tissue-building.  The  upper  limit  of 
a  healthy  infant's  temperature,  except  just  after  birth  when  it  is  some- 
times lower,  is  probably  about  half  a  degree  higher  than  in  the  adult. 
AVith  regard  to  this  point,  however,  as  indeed  to  the  whole  subject  of 

l6l  T 


102  ACUTE  FEBRILE  DISEASES. 

temperature  in  children  I  would  refer  the  reader  to  a  valuable  paper  by 
Dr.  Sturges  in  vol.  ii.  of  the  Westminster  Hospital  Eeports  (1886).  It 
has  been  a  common  observation  at  Shadwell  that  the  temperature  of 
young  children  is  very  frequently  raised  some  degrees  not  only  on 
admission  to  hospital,  but  also  on  visiting  days,  the  chart  in  many 
instances  giving  a  fairly  accurate  record  of  those  occasions.  Fits  of 
crying,  moreover,  convulsions,  or  other  excitements,  are  often  accom- 
panied by  a  marked  rise  of  temperature.  Even  in  the  course  of  enteric 
•fever  the  irregularity  of  the  pyrexia  of  childhood  may  be  exemplified, 
the  temperature  being  often  remittent  and  daily  touching  the  normal 
line  even  at  the  height  of  the  illness.  This  fact  adds  obscurity  to 
some  cases  of  difficult  diagnosis  between  tuberculosis  and  enteric  fever. 
Notable  instances  of  high  temperature  may  frequently  be  observed  in 
cases  of  affections  of  the  nervous  centres  in  childhood,  such  as  tumours 
or  sometimes  hsemorrhages,  which  in  adults  would  be  unaccompanied  by 
pyrexia.  Again,  in  a  case  at  "Westminster  Hospital  of  what  proved  post- 
mortem to  be  extensive  hydrocephalus  in  a  child  of  two  and  a  half  years 
old  whose  fontanelles  were  quite  closed,  the  temperature  had  almost  daily 
risen  to  1030  or  1040  during  some  months,  the  child  being  apparently 
well  in  the  apyretic  intervals  and  showing  no  signs  of  local  lesion  until 
some  weeks  before  death,  when  clear  evidence  of  headache  and  recurrent 
convulsions-  led  to  the  erroneous  diagnosis  of  cerebral  abscess.  The 
tympanic  membranes  had  been  punctured  late  in  the  case  on  the  sus- 
picion of  an  undiscoverable  otitis,  but  the  ear  structures  were  found  to 
be  quite  healthy  post-mortem. 

In  the  light  of  these  considerations  we  should  not  wonder  if  we  are 
from  time  to  time  quite  unable  to  make  any  definite  diagnosis  of  the 
cause  of  both  ephemeral  and  persistent  pyrexia  in  children  ;  but  we  must 
none  the  less  make  searching  and  repeated  examinations  of  the  whole 
body  before  pronouncing  on  the  nervous  origin  of  any  given  case,  bearing 
in  mind  that  very  slight  organic  trouble,  which  in  adults  would  be  marked 
by  but  little  disturbance,  may  cause  a  considerable  amount  of  fever  in  a 
child.  Passing  over  most  local  inflammations  and  the  exanthemata,  which 
must  of  course  always  be  thought  of  and  are  dealt  with  elsewhere,  I 
would  emphatically  mention  here  the  frequency  with  which  a  pneumonia, 
with  but  slight  or  sometimes  with  no  discoverable  signs  of  lung-consolida- 
tion, may  escape  notice  in  young  children ;  and  also  the  highly  important 
fact  that  suppurative  otitis  may  be  the  cause  of  long-enduring  fever, 
either  of  a  remittent  or  less  often  of  a  continued  type,  which,  in  the 
frequent  absence  of  evidence  of  any  local  pain,  especially  in  infants, 
may  remain  undiagnosed  for  long  unless  the  tympanic  membranes  be 
examined  or  punctured,  and  may  be  regarded  as  enteric  fever,  tuber- 
culosis,  or  some  other  less  definite  febrile   affection  under  the  vague 


PYREXIA.  163 

name  of  septicaemia.  The  fauces  should  of  course  be  examined  in  any 
case  of  doubtful  pyrexia,  for,  although  there  may  be  no  symptoms,  a 
tonsillitis  may  exist ;  and  I  need  hardly  add,  except  for  the  frequency 
with  which  small  empyemata  are  missed,  that  we  need  not  hesitate  to 
puncture  the  pleura  when  we  have  a  suspicion  from  physical  signs  of  a 
collection  of  pus. 

A  common  form  of  febrile  attack  may  be  most  appropriately  men- 
tioned here,  as  it  is  with  difficulty  placed  without  dispute  in  any  definite 
category.  I  allude  to  cases  which  are  very  frequently  recurrent  in  some 
children,  and  characterized  by  a  sudden  and  considerable  rise  of  tem- 
perature, rapid  breathing  with  perhaps  some  rhonchi  or  scattered  rales 
discoverable  on  auscultation,  headache,  drowsiness  and  sometimes  vomit- 
ing. These  symptoms  may  last  for  some  days  and  gradually  subside. 
By  many  these  attacks  are  regarded  as  due  to  gastric  catarrh,  even  when 
unaccompanied  by  vomiting  or  intestinal  disturbance  and  not  preceded 
by  any  dietetic  error ;  and  by  others  they  are  looked  upon  as  "  gastro- 
pulmonary  "  fever.  Dr.  Goodhart,  using  the  latter  term,  insists  upon  the 
frequency  of  marked  signs  of  acute  bronchitis  in  these  cases,  and  believes 
that  they  are  the  analogues  of  asthma  in  older  children.  In  my  own 
experience  it  has  been  by  no  means  the  rule  to  find  any  physical  signs 
in  the  chest  at  all,  but  usually  only  a  much  increased  rate  of  breathing 
in  proportion  to  the  height  of  the  fever ;  and  the  extremely  acute  cases, 
simulating  bronchitis  but  rapidly  convalescing,  described  as  so  frequent 
by  Dr.  Goodhart  I  have  not  as  yet  recognised.  I  have,  however,  long- 
been  impressed  with  the  fact  that  the  attacks  I  mention,  which  seem  to 
be  of  the  same  nature,  are  in  no  demonstrable  way  connected  with  gastric 
disturbance,  although  almost  always  both  medically  and  popularly  regarded 
and  treated  as  such.  They  are  much  more  often  the  immediate  sequel 
of  marked  excitement,  and  are  especially  apt  to  occur  in  nervous  children 
with  other  evidence  of  neurotic  disturbance.  I  therefore  strongly  incline 
to  Dr.  Goodhart's  interpretation  of  their  meaning  and  pathology. 

Having  seen  several  typical  cases  of  ague  in  children  who  have  always 
lived  near  the  London  Thames,  both  in  the  neighbourhood  of  the  docks 
and  in  Westminster,  I  cannot  but  recognise  the  possibility  of  some  of  the 
numerous  obscure  cases  we  meet  with  in  children  of  intermittent  pyrexia 
(without  rigors  or  a  marked  sweating  stage  or  splenic  enlargement  or  even 
much  anaemia),  being  due  to  the  malarial  poison.  I  have  notes  of  not  a 
few  cases  of  this  kind  in  both  young  and  older  children,  where  the  fever 
has  yielded  to  quinine  or  recurred  on  its  omission,  .and  has  disappeared 
entirely  after  a  more  or  less  prolonged  use  of  this  remedy. 

Febrile  attacks  in  infancy  and  early  childhood,  apart  from  the  specific 
exanthemata,  are  often  accompanied  by  a  more  or  less  extensive  cutaneous 
blush,  especially  on  the  face  and  trunk,  which,  although  usually  evanescent 


I  64  ACUTE  FEBRILE  DISEASES. 

and  shifting  in  position,  may  last  for  a  few  days.  This  may  be  seen  in 
tonsillitis,  in  pneumonia,  in  acute  gastric  catarrh  with  definite  cause  and 
symptoms,  in  the  presumably  nervous  fevers  above  mentioned  and  in 
other  febrile  conditions.  It  is  often  mistaken  for  and  sometimes  with 
difficulty  distinguished  from  a  scarlatinal  rash ;  but  usually  it  occupies 
the  whole  of  the  face  without  leaving  the  white  margin  round  the  nose 
and  lips  which  is  almost  always  seen  in  scarlatina. 

In  all  febrile  conditions  of  children,  especially  in  infants,  wasting  both 
of  fat  and  muscle  is  much  more  prominent  than  in  adults,  and  there  is 
often  marked  weakness  of  limbs  with  considerable  pain.  Sweating  is 
■on  the  whole  of  rarer  occurrence  in  the  fever  of  childhood,  and  it  is 
exceedingly  difficult,  as,  for  example,  in  the  case  of  pneumonia  when 
the  skin  is  often  dry  and  pungently  hot,  to  bring  about  diaphoresis 
by  even  more  than  the  adtdt  doses  of  such  a  medicine  as  the  liquor 
ammonise  acetatis.  Herein  lies  a  partial  explanation  of  the  higher 
range  of  temperature  so  often  maintained  in  children,  and  an  encourage- 
ment to  allow  the  feverish  child  to  be  as  slightly  covered  as  possible  and 
to  have  plenty  of  fresh  air.  Delirium,  as  a  rule,  is  but  slightly  marked 
in  early  childhood. 

It  must  be  confessed,  as  it  will  be  inferred  from  the  above  remarks, 
that,  owing  probably  to  the  nervous  peculiarity  of  childhood,  there 
remains,  even  after  the  expenditure  of  all  diagnostic  care  and  acumen, 
-a  certain  number  of  cases  of  pyrexia  with  no  local  or  otherwise  definite 
explanation.  We  must,  however,  never  forget  the  frequency  of  tuber- 
culosis, in  which  remittent  fever  and  some  wasting  may  be  for  long  the 
•only  discoverable  signs. 


CHAPTER    II. 

DIPHTHERIA. 

By  this  term  we  understand  a  contagious  febrile  disease  of  both  sporadic 
and  epidemic  occurrence,  marked  for  the  most  part  by  a  more  or  less 
tenacious  pellicle  or  membrane  in  the  fauces  and  naso-pharynx  which 
often  involves  the  larynx  and  trachea  as  well,  and  in  many  cases 
■occupies  the  smaller  bronchi,  frequently  setting  up  varying  degrees  of 
broncho-pneumonia.  Albuminuria  is  observed  in  a  considerable  pro- 
portion of  cases,  and  certain  paralyses  are  apt  to  appear  either  in  the 
course  of  the  disease  or  after  general  convalescence  is  established. 
Both  the  frequency  and  the  fatality  of  this  affection  are  by  far  the 


DIPHTHERIA.  l6$ 

greatest  in  children  under  two  years  of  age.  The  cause  of  diphtheria 
is  in  all  probability  a  specific  bacillus  which,  under  certain  conditions, 
invades  the  mucous  membrane  of  the  pharynx  and  nose,  and  generates 
there  a  rapidly  absorbable  poison  with  frequently  wide-spreading  con- 
stitutional effects.  Nearly  half  of  those  attacked  under  ten  years  of 
age  die,  the  immediate  causes  of  death  being  mostly  either  profound 
blood-poisoning;  obstruction  in  some  part  of  the  respiratory  tract;  a 
combination  of  these  conditions ;  cardiac  paralysis,  which  in  most, 
although  not  all,  of  its  instances  takes  place  after  the  subsidence  of  the 
acute  symptoms  of  the  disease ;  or  suppression  of  urine. 

The  question  whether  a  membranous  deposit  is  always  and  everywhere 
of  diphtheritic  origin  must  in  my  opinion,  with  our  present  knowledge, 
be  answered  at  least  provisionally  in  the  negative.  There  are  not  only 
many  cases  of  scarlatinous  and  other  affections  of  the  fauces  with  a 
membranous  appearance  indistinguishable  from  that  of  diphtheria,  but 
also,  and  especially  in  quite  young  children,  frequent  instances  of  laryngo- 
tracheitis  which  have  nothing  in  common  with  diphtheria,  either  in  their 
course,  conditions  or  sequelae,  other  than  the  presence  of  membrane  in 
the  respiratory  tract  strictly  below  the  epiglottis,  the  fauces  and  nares 
being  found  free  from  involvement  both  during  life  and  after  death. 
Of  this  latter  fact  I  have  quite  convinced  myself  by  necroscopical 
observations,  bearing  ever  in  mind  that  diphtheritic  deposit  in'  the 
nares,  with  little  or  no  faucial  involvement,  may  be  undetectable  at 
the  bedside  and  overlooked  in  the  post-mortem  room.  I  have  else- 
where stated  some  grounds  for  my  belief  in  a  non-contagious  mem- 
branous laryngitis  apart  from  diphtheria,  and  space  forbids  me  to 
enter  again  at  any  length  into  this  much-debated  question.  I  would 
however  point  out  here  that,  besides  the  generally  admitted  occurrence 
of  membranous  laryngitis  from  a  traumatic  cause,  such  as  scalds  from 
boiling  water,  there  is  the  frequent  and  unquestionable  fact  of  membrane 
being  coughed  up  for  the  first  time,  some  days  after  tracheotomy  for 
laryngeal  obstruction,  in  cases  where  there  had  been  no  sign  of  membrane 
anywhere  either  before  or  during  the  operation.  I  have  seen  several 
instances  of  severe  laryngitis  with  normal  fauces  and  no  nasal  obstruction 
or  discharge  where,  at  tracheotomy,  after  careful  search  and  feathering- 
out  of  the  larynx  and  trachea,  no  trace  of  membrane  was  discovered ; 
but  where,  some  days  after  the  tube  had  been  in  position,  coherent  mem- 
brane was  frequently  expelled,  unaccompanied  by  any  febrile  or  other 
symptoms  of  advancing  diphtheria,  and  sometimes  disappearing  rapidly 
after  the  removal  of  the  silver  tube  or  its  substitution  by  a  soft  one.  Such 
cases  as  these,  which  usually  recover  without  any  sequela?,  point  strongly 
to  the  probability  of  the  membranous  deposit  being  due  to  the  traumatism 
of  the   tube,   and,   in   default  of  any  bacteriological  or  other  definite 


J  66  ACUTE  FEBRILE  DISEASES. 

evidence  of  the  universally  specific  character  of  membranous  deposit 
anywhere,  I  cannot  avoid  the  conclusion,  hased  at  least  on  ample 
clinical  grounds,  that  many  apparently  idiopathic  and  uncomplicated 
cases  of  membranous  laryngitis  in  quite  young  children  are  simply 
inflammatory  or  at  least  non-diphtheritic  in  origin.  I  would  acid  here, 
moreover,  that  such  laryngitis  is  sometimes  concomitant  with  ton- 
sillar ulceration  or  general  pharyngitis,  of  which  measles  supplies  some 
examples  ;  and  would  therefore  endorse  the  teaching  of  the  late  Dr.  Fagge 
that  not  all  pharyngeal  accompaniments  of  membranous  laryngitis  are  to 
be  regarded  as  evidence  of  diphtheria. 

The  main  practical  lesson  I  draw  from  this  belief  in  a  non-diphtheritic 
membranous  laryngitis  is  that,  without  good  evidence  of  diphtheria  other 
than  the  suspected  or  proved  existence  of  laryngotracheal  membrane, 
cases  of  laryngitis  should  not  be  treated  in  company  with  recognised 
diphtheria,  and  should  therefore  not  be  admitted  into  the  diphtheria 
wards  of  hospitals  where  the  contagium  is  probably  greatly  reinforced 
by  numbers.  As  regards  diagnosis,  I  admit  to  the  full  that  it  is  often 
practically  impossible  to  differentiate  severe  and  especially  membranous 
larnygitis  from  that  of  diphtheritic  origin ;  and  I  have  known  several 
cases  which  during  life  were  to  all  appearance  purely  laryngitic  but  were 
found  after  death  to  be  marked  by  membrane  on  the  nose  or  upper  part 
of  the  pharynx.  It  is,  further,  true  that  although  epidemic  diphtheria 
is  nearly  always  prominently  pharyngeal,  and  the  usually  sporadic 
membranous  laryngitis  rarely,  if  ever,  spreads  to  others,  yet  cases  of 
seemingly  pure  laryngitis  occasionally  occur  side  by  side  with  recog- 
nised diphtheria  of  epidemic  character. 

As  a  matter  of  practice,  therefore,  in  default  especially  of  any  clinically 
available  and  definite  test  of  specificity,  I  would  regard,  at  least  pro- 
visionally, all  cases  of  membranous  deposit  in  the  fauces,  nares  or  air- 
passages  as  diphtheritic  in  nature  until  such  time  as  the  appearance  of 
symptoms  significant  of  other  diseases,  or  the  continuous  absence  of  those 
characteristic  of  diphtheria,  may  render  this  diagnosis  untenable  or  im- 
probable. With  regard  to  those  numerous  cases  where  the  symptoms 
of  laryngotracheal  obstruction  are  alone  observed,  it  must  be  remarked 
that  their  membranous  nature  is  only  to  be  inferred  as  a  rule  from  our 
knowledge  that  most  severe  and  ingravescent  cases  of  laryngitis  are  as 
a  matter  of  fact  membranous ;  for,  apart  from  the  rare  occurrence  of 
expectoration,  the  fact  of  membranous  deposit  can  only  be  positively 
established  by  tracheotomy  or  death. 

There  may  be  some  hope  that  the  microscopical  detection,  by  staining 
methods,  of  the  Klebs-Lcefner  bacillus,  corroborated  by  culture  observa- 
tions, may  come  into  general  clinical  use  and  thus  afford  some  means 
of  accurately  distinguishing  between  diphtheritic  and  non-diphtheritic 


DIPHTHERIA.  1 67 

membranous  deposit.  Baginsky  has  reported  cases  where  l>y  tliis  means 
lie  differentiated  two  classes  of  membranous  deposits,  the  one,  marked 
by  the  presence  of  the  bacillus  diphtheria,  with  a  mortality  of  50  per 
cent.;  the  other,  marked  by  streptococci  and  other  organisms,  being 
always  of  favourable  event.  The  time  is,  however,  probably  far  distant 
when  the  non-discovery  of  the  presumably  specific  bacillus  may  be  re- 
garded as  a  satisfactory  negative  test  of  diphtheria  or  justify  us  in 
disregarding  other  possible  indications  of  this  disease. 

Sources  and  Spread  of  the  Contagium. — We  have  seen  that  the 
disease  is  pre-eminently  one  of  childhood.  It  is  very  rare  before  the 
sixth  or  seventh  month  or  during  the  period  of  exclusive  suckling,  and 
its  frequency  rapidly  rises  up  to  the  fourth  or  fifth  year  and  as  rapidly 
declines  till  about  the  tenth  year.  Of  140  cases  of  all  ages  observed  by 
Mr.  James  Dickinson  at  the  Homerton  Fever  Hospital  three-fourths 
were  under  two  years  old.  It  is  certain  that  a  very  large  number  of 
these  youthful  cases,  occurring,  as  they  often  do,  among  the  well-to-do 
and  in  country  districts  where  there  is  no  crowding,  are  not  to  be 
referred  to  direct  personal  communication ;  and  this  is  quite  in  accord 
with  the  fact  that  doctors  and  nurses  in  constant  contact  with  large 
numbers  of  even  the  worst  cases  in  hospital  are  but  rarely  infected, 
except  in  certain  circumstances.  My  own  experience  strongly  corro- 
borates the  teaching  that  by  far  the  most  frequent  mode  of  infection 
is  through  the  actual  invasion  of  the  mucous  membrane  by  the  exudative 
material  from  a  diphtheritic  throat,  and  in  my  own  hospital,  where  for 
many  years  diphtheria  was  admitted  into  the  general  wards,  I  have 
scarcely  ever  had  reason  to  suspect  its  spread  in  any  other  way.  On 
the  few  occasions  when  other  children  in  the  ward  apparently  took  the 
disease  there  was  almost  always  a  possibility  and  generally  proof  of  their 
having  been  in  close  contact  with  diphtheritic  patients,  except  sometimes 
when  numerous  cases  of  diphtheria  were  being  simultaneously  treated — 
a  condition  which  I  regard  as  probably  greatly  reinforcing  the  activity 
of  the  contagium  at  a  distance.  I  believe,  further,  that,  apart  from  the 
apparently  striking  predisposition  of  certain  families  to  take  the  disease, 
a  certain  morbid  condition  of  the  naso-pharynx  is  a  most  important 
factor  in  the  morbific  action  of  the  organic  cause ;  for,  leaving  out  of 
account  the  doubtful  cases  of  diphtheritic  sore  throat  with  fibrinous 
exudation  which  occur  in  the  course  of  scarlatina,  measles,  enteric 
fever  and  other  affections,  diphtheria  with  all  its  clinical  marks  is  un- 
doubtedly often  seen  sooner  or  later  after  these  diseases,  and  especially 
after  scarlatina.  Examples  of  this  connexion  are  very  frequent  in 
hospitals,  and  diphtheria  epidemics  are  often  preceded  by  apparently 
non-specific  sore  throat.  It  is  indeed  highly  probable  that  an  unhealthy 
or  injured  condition  of  the  mucosa  of  the  naso-pharynx  or,  possibly,  of 


I  68  ACUTE  FEBRILE  DISEASES. 

the  upper  air-passages  is  an  enormously  important  and  perhaps  even  a 
necessary  factor  in  the  production  of  diphtheria  without,  or  perhaps 
even  with,  actual  contact  with  the  exudative  material  which  bears  the 
contagium. 

Of  the  a3tiological  conditions  and  vitality  of  the  contagium  outside  the 
body  we  know  but  little  for  certain  in  spite  of  much  research  and  more 
speculation.  It  is  said,  with  the  support  of  much  evidence,  to  remain  long 
potentially  active  in  clothes,  bedding,  soil  and  elsewhere,  and  therefore 
to  be  possibly  communicable  by  persons  themselves  uninfected.  Cold 
and  damp  I  believe,  both  from  authority  and  experience,  to  be  certainly 
favourable  to  its  energy,  and  there  is  valuable  evidence  to  show  that 
milk-supply  from  cows  probably  suffering  from  the  disease  in  some  form, 
and  contact  with  animals,  especially  cats  and  fowls,  infected  by  human 
or  other  diphtheritic  matter,  are  more  or  less  frequent  sources  of  in- 
fection. It  is  further  highly  probable  that  the  massing  together  in 
schools  or  other  assemblies  of  large  numbers  of  young  children,  some 
of  whom  are  infective,  is  sometimes  a  powerful  cause  of  epidemic  spread. 
I  will  oidy  add  to  this  bare  statement  of  setiological  belief,  based  on  study 
and  experience  of  these  difficult  matters,  that  I  know  of  little  positive 
evidence  of  the  spread  of  diphtheria  by  drains  or  drinking  water ;  but 
regard  it  as  at  least  exceedingly  likely  that  the  potential  contagium  may 
exist  for  long  in  the  soil  and  in  refuse  heaps  of  animal  matter,  and  that 
its  energy  may  be  excited  by  certain  physical  conditions.  Until,  how- 
ever, we  acquire  a  sounder  aetiological  knowledge  of  diphtheria  we  shall 
remain  mostly  powerless  for  rational  and  effective  prophylaxis. 

The  incubation  period  of  the  contagium  in  the  body  may  be  certainly 
as  short  as  two  days  or  probably  shorter.  Its  maximum  limit  is  difficult 
to  fix  owing  to  the  frequently  insidious  onset  of  the  symptoms  of  the  dis- 
ease. It  may  be  at  least  a  week.  Of  a  longer  period,  probable  though 
it  be,  we  have  no  certain  information. 

Symptoms  and  Course.— The  onset  of  diphtheria  is  marked  in  most 
cases  by  malaise,  headache  sometimes  very  severe,  some  fever,  and  a 
feeling  of  soreness  in  the  throat ;  but  often  enough  both  local  and  general 
complaints  are  slight  even  when  extensive  deposit  is  seen  on  examina- 
tion of  the  fauces.  If  the  throat  be  examined  quite  at  the  outset,  only 
swelling  and  dark  redness  are  usually  apparent,  or  patches  of  yellowish 
deposit  indistinguishable  from  that  seen  in  follicular  tonsillitis  or  scarlet 
fever ;  but  this  is  generally  followed  in  a  day  or  two  by  a  coherent  and 
adherent  exudation  which  occupies  the  tonsils,  especially  at  their  opposed 
surfaces,  and  most  often  involves  other  parts  of  the  pharynx.  When 
the  tonsils  only  are  covered  with  a  membranous  exudation,  and,  still 
more,  when  one  is  affected  alone  or  a  day  or  two  before  the  other,  the 
case  need  not  be  diphtheritic  in  the  absence  of  other  symptoms,  but  may 


DIPHTHERIA.  1 69 

be  one  of  scarlatina  or  of  follicular  tonsillitis.  Membranous  involve- 
ment of  the  uvula,  soft  palate  or  back  of  the  pharynx,  confusion  of  which 
with  inspissated  nasal  mucus  must  always  be  duly  avoided,  is  most 
important  local  evidence  of  diphtheria ;  as  also  is  the  presence  of  sero- 
purulent  or  sanious  discharge  from  the  nostrils.  In  the  absence  of  these 
two  marks  we  are  helped  towards  a  diagnosis  by  remembering  that  cases 
of  sudden  onset  of  illness  with  severe  faucial  symptoms,  high  fever,  and 
especially  a  history  of  previous  similar  attacks  are  usually  not  diph- 
theritic, however  difficult  of  differentiation  the  appearances  on  the  tonsils 
may  be.  Much  swelling  or  tenderness  of  the  glands  in  the  neck  is  not 
frequent  in  diphtheria,  unless  either  the  spreading  of  the  membrane 
beyond  the  tonsils  be  well-marked,  or  there  be  nasal  discharge  or 
severe  constitutional  symptoms  ;  and  when  such  swelling  occurs  sud- 
denly we  should  rather  think  of  scarlet  fever.  It  is,  with  few  excep- 
tions, in  the  gravest  cases  only  of  diphtheria  that  extensive  glandular 
swelling,  with  or  without  areolar  infiltration,  is  seen.  In  several  cases  I 
have  noted  the  absence  of  all  glandular  enlargement,  but  it  is  mostly 
present  in  some  degree,  especially  behind  the  angle  of  the  jaw,  as  indeed 
it  is  in  other  forms  of  tonsillitis.  The  nasal  discharge  above-mentioned 
is  sometimes  the  first  observed  sign  of  diphtheria,  and  must  always, 
when  copious  and  continued,  be  regarded  as  of  bad  prognostic  import. 
It  is  usually  thinly  purulent  or  sanious  and  often  excoriates  the  nostrils 
and  upper  lip.  Sometimes  severe  epistaxis  occurs  and  is  of  grave 
meaning,  implying  considerable  diphtheritic  involvement  of  the  nares. 
It  is  a  favourable  sign,  on  the  whole,  when  the  discharge  becomes  thickly 
purulent.  In  the  absence  of  well-marked  membrane  in  the  nose  or 
fauces  we  cannot  always  quite  distinguish  the  diphtheritic  nasal  dis- 
charge from  that  of  scarlatina,  but  apart  from  this  the  diagnostic  value 
of  the  rhinitis  described  can  scarcely  be  over-rated.  Occasionally 
an  exudation  on  the  lips  or  buccal  mucous  membrane,  resembling 
confluent  patches  of  stomatitis,  is  observed  before  other  local  signs  of 
diphtheria  are  manifested.  In  rare  instances,  examples  of  which  I  have 
never  seen,  diphtheria,  according  to  unquestionable  authorities,  may 
begin  on  the  conjunctiva,  the  external  genitals  or  on  the  morbidly 
or  traumatically  abraded  skin,  and  in  such  cases  the  pharynx  may 
be  unaffected. 

Larijngo-tracheal  symptoms  are  not  infrequently  observed  early,  and 
may  be  urgent  before  further  signs  of  diphtheria  are  manifest.  Such 
cases  present  of  necessity  much  difficulty  of  diagnosis  until  there  be 
evidence  of  membrane  in  nose  or  fauces ;  and  sometimes  are  only  recog- 
nised with  certainty  on  post-mortem  examination,  especially  when  the 
membrane  is  confined  to  the  upper  part  of  the  pharynx  or  involves  only 
the  posterior  surface  of  the  soft  palate.     In  my  experience  membranous 


170  ACUTE  FEBRILE  DISEASES. 

laryngitis  is  mostly  an  early  phenomenon  when  it  occurs  in  diphtheria, 
and  the  naso-pharyngeal  signs  much  oftener  follow  than  precede  the 
laryngotracheal.  In  only  a  small  minority  of  my  cases  has  severe  croup 
followed  on  diphtheritic  disease  after  an  interval  of  more  than  three  or 
four  days,  and  a  large  majority  of  those  which  required  tracheotomy 
to  relieve  urgent  symptoms  Avere  admitted  as  cases  of  "croup"  from 
the  first. 

That  diphtheria  may  exist  without  any  unmistakable  local  signs  or 
symptoms  in  pharynx  or  larynx  is  undoubtedly  true,  as  is  evidenced  by 
the  occurrence  of  paralysis  of  the  diphtheritic  pattern  after  very  slight 
attacks  of  sore  throat.  In  such  cases  the  local  affection  is  probably  mainly 
nasal  and  escapes  observation.  The  allegation,  however,  that  diphtheritic 
paralysis  is  as  a  rule  the  sequel  of  indefinite  or  undiscovered  rather  than 
of  severe  attacks  is  incorrect,  being  based  not  on  observation  and  the 
tracing  out  of  the  events  of  diphtheritic  cases  but  rather  on  inference, 
owing  to  the  absence  of  diphtheritic  history  in  some  cases  of  paralysis 
Avhich  at  first  sight  appear  to  belong  to  the  so-called  diphtheritic  ■  cate- 
gory. The  records  of  large  numbers  of  cases  of  diphtheria  show  that 
paralysis  is  most  often  preceded  by  well-marked  attacks. 

The  paralyses  which  are  especially  associated  with  diphtheria  are  for 
the  most  part  of  only  retrospective  value  in  diagnosis,  for  they  most 
often  occur  after  the  subsidence  of  acute  symptoms  or  quite  late  in 
convalescence.  I  shall  allude  further  to  this  subject  in  the  section  on 
"Disorders  of  the  Nervous  System."  Paralysis  of  the  pharynx  and  soft 
palate  may  occur  early,  but  the  return  of  swallowed  fluids  through  the 
nose  is  sometimes  caused  by  impaired  palatal  movement  from  local 
swelling  apart  from  nerve  paralysis.  Weakness  of  the  ciliary  muscle, 
shown  by  loss  of  near  accommodation,  is  next  in  order  of  frequency,  and 
strabismus  of  some  kind  is  not  very  rare.  Any  or  almost  all  of  the 
muscles  may  be  involved  in  turn,  including  those  of  the  larynx  and 
of  respiration  generally.  Paralysis  of  the  diaphragm  is  always  a  part 
of  more  wide-spread  mischief  and,  when  marked,  is  mostly  fatal.  It 
is  evidenced  by  stillness  or  recession  of  the  epigastrium  in  inspiration, 
increased  expansion  of  the  lower  part  of  the  thorax  and  feebleness  of 
voice  and  cough.  Dr.  W.  Pasteur  has  specially  studied  this  condition 
and  draws  attention  to  its  frequent  association,  which  he  believes  to  be 
causal,  with  pulmonary  collapse  and  broncho-pneumonia.  Affection  of 
the  heart,  characterized  by  either  slowness  and  irregularity  or,  more 
frequently,  by  great  rapidity  of  action  and  often  ending  in  almost  sudden 
death,  is  an  ever-present  clanger  in  diphtheria,  especially  when  other  para- 
lyses exist.  It  may  occur  early,  although  it  is  oftener  a  latish  sequel. 
I  have  seen  two  cases  of  sudden  death  from  this  cause  in  patients  who 
were  up  and  about ;  one  of  whom  had  had,  unknown  to  me,  some  slight 


DIPHTHERIA.  I  7  I 

paralysis  of  the  velum  palati ;  while  the  other  was  absolutely  free  from 
all  paralytic  symptoms,  and  had  been  allowed  to  get  up  three  days  after 
an  attack  of  exudative  tonsillitis  which  had  heen  decided  on  many 
apparently  conclusive  grounds  to  be  non-diphtheritic  in  nature.  Only 
one  tonsil  was  affected,  there  was  no  albuminuria,  and  the  hoy  had  heen 
long  in  an  adult  ward,  suffering  from  chorea  and  unexposed,  as  far  as 
we  knew,  to  any  source  of  diphtheritic  contagion.  In  some  of  these 
cases  the  heart-muscle  is  found  to  he  fattily  degenerated,  but  certainly 
not  in  all.  Collapse  or  death  from  this  cause  is  often  preceded  by  severe 
precordial  or  abdominal  pain. 

The  knee-jerks  are  usually  absent  in  diphtheritic  paralysis,  returning, 
though  sometimes  after  a  long  interval,  when  health  is  perfectly  re- 
established. They  are,  however,  frequently  absent  in  diphtheria  without 
paralysis,  but  may  be  well-marked  throughout  in  cases  which  subsequently 
develop  paralysis,  when  they  may  or  may  not  disappear.  When  diph- 
theritic paralysis  affects  the  legs  the  knee-jerks  are,  I  believe,  always 
absent.  I  would  remark  here,  as  possibly  bearing  on  the  vexed  question 
of  the  identity  of  croup  and  diphtheria,  that,  in  those  cases  of  proved 
membranous  laryngitis  without  other  signs  of  diphtheria  which  require 
tracheotomy  and,  in  children  over  three  or  four  years  old,  not  infre- 
quently recover,  paralysis  of  the  kinds  above-mentioned  is  practically 
unknown. 

Albuminuria  occurs  in  a  considerable  majority  of  the  unquestionable 
cases'  of  diphtheria,  and  mostly  in  a  marked  degree.  It  generally 
appears  on  about  the  third  or  fourth  day  of  the  disease,  too  late  to  he  of 
much  help  in  the  great  difficulty  of  initial  diagnosis.  The  nephritic 
albuminuria  of  scarlet  fever  is  however  usually  of  much  later  date. 
Diphtheritic  albuminuria  is  almost  always  unaccompanied  by  oliguria, 
hematuria  or  dropsy,  and  is  but  very  rarely  followed  by  chronic  nephritis. 
Its  amount  and  frequency  seem  to  vary  much  in  different  epidemics,  and 
cannot  be  ranked  as  of  very  important  prognostic  value.  I  have,  how- 
ever, observed  a  continuous  absence  of  albuminuria  in  several  undoubted 
cases  of  mild  type,  and  it  is  in  the  severest  cases  that  it  is  most  copious 
and  enduring.  Nephritis  is  often  found  post-mortem  but  is  not  charac- 
teristic.    Hematuria  I  have  seen  in  but  two  cases,  both  fatal. 

The  temperature  even  in  very  severe  cases  is  as  a  rule  not  high, 
averaging  between  100°  and  102.50.  The  disease  however  is  almost 
always  dangerous  when  the  initial  or  early  temperature  is  over  103°, 
and  a  persistently  high  temperature  is  of  the  gravest  import.  It  is 
often  associated  with  a  very  frequent  pulse,  great  lessening  or  absence 
of  the  first  heart-sound,  somnolence,  loss  of  appetite  and  vomiting ;  and 
there  may  be  severe  nasal  affection  without  much  faucial  trouble. 

Certain  rashes,  mostly  erythematous  or  roseolous,  occur  occasionally 


172  ACUTE  FEBRILE  DISEASES. 

in  diphtheria.  I  have  seen,  however,  only  a  few  undoubted  instances 
Avhere  scarlet  fever  could  he  positively  excluded.  In  one  case  with 
protracted  convalescence  a  wide-spread  erythema  occurred  on  the  sixth 
day  and  again  on  the  twenty-seventh  day  after  the  onset  of  the  disease. 

Vomiting  of  a  persistent  character  occurs,  as  a  late  symptom,  in  a 
certain  proportion  of  cases,  mostly  fatal.  It  is  in  these  instances  that 
marked  slowness  of  the  pulse  is  especially  noted,  and,  as  has  recently 
been  insisted  on  in  a  valuable  paper  by  Dr.  G.  G.  Morrice,1  complete  or 
nearly  complete  suppression  of  urine  is  a  very  prominent  feature.  This 
observer  of  large  numbers  of  cases  at  Homerton  Fever  Hospital  describes 
cases  with  an  early  fall  of  pulse-rate,  some  of  which  may  slowly  recover 
after  a  stationary  period  of  some  days,  while  in  others  there  is  a  rapid 
acceleration,  with  extreme  irregularity,  of  pulse,  followed  by  death.  A 
steady  diminution  of  urinary  flow  coincides  with  this  condition,  bearing, 
however,  no  apparent  relation  to  the  degree  of  albuminuria.  Yomiting 
begins  usually  about  twenty-four  hours  before  death,  and  during  the 
last  day  only  a  few  drachms  of  urine  are  passed.  Dr.  Morrice  adds  that 
there  is  no  coma,  and  no  relation  to  at  least  palatal  paralysis ;  and  that, 
very  rarely,  convulsions  precede  death.  The  bladder  is  found  post- 
mortem to  be  quite  empty  and  contracted,  and  the  kidneys  are  in  a 
state  of  acute  nephritis.  In  the  cases  which  recover  increased  urinary 
flow  accompanies  the  pulse's  return  to  the  normal. 

Mortality  and  Prognosis. — Fatal  diphtheria  is  not  common  over  ten 
and  most  frequent  under  five  years  old.  Mr.  Dickinson's  statistics  above 
quoted,  based  on  cases  of  all  ages,  show,  in  general  accordance  with  my 
own  and  others'  records,  that  while  nearly  half  of  those  attacked  under 
ten  die,  nearly  nine-tenths  over  that  age  recover.  In  the  younger  set 
we  find  an  immense  majority  of  the  "croup"  and  "nasal"  cases.  I 
cannot  fix  the  mortality  between  one  and  four  years  of  age  lower  than 
75  per  cent.  In  the  first  six  or  seven  months  the  disease  is  decidedly 
rare.  Were  we  to  reckon  as  diphtheritic  all  cases  of  apparently  pure 
membranous  laryngitis,  both  the  incidence  and  the  fatality  of  the  disease 
in  the  first  three  years  of  life  would  be  considerably  greater.  Involve- 
ment of  the  upper  air-passages  is  always  a  mark  of  great  gravity,  scarcely 
one-fourth  of  the  cases  recovering ;  and  a  peculiarly  excoriating  nasal 
discharge  is  mostly  seen  in  fatal  cases.  It  is,  however,  to  be  insisted  on 
that  a  very  large  number  of  patients  dying  with  laryngo-tracheal  involve- 
ment succumb,  not  to  the  mechanical  effects  of  membrane  in  the  air- 
passages,  but  to  the  stress  of  the  diphtherial  poison,  which  becomes 
manifest  before,  or  more  frequently  after,  the  occurrence  of  laryngeal 
symptoms.     There  are  indeed  numerous  cases  Avhere  respiratory  difficulty 

1  See  St.  Bartholomew's  Hospital  Reports,  vol.  xxviii.,  "On  Suppression  of  Urine 
Diphtheria." 


DIPHTHERIA.  173 

is  completely  relieved  and  immediate  death  prevented  by  tracheotomy, 

but  which  arc  killed  by  the  general  effects  of  the  poison  or  by  cardiac 
paralysis.  Broncho-pneumonia,  too,  is  a  prominent  cause  of  death,  even 
when  the  upper  air-passages  are  but  little  or  not  at  all  affected.  It  is 
possible  that  the  great  frequency  of  broncho-pneumonia  is  due  to  the 
inhalation  of  diphtheritic  material  from  the  naso-pharynx.  However 
this  may  be,  it  is  almost  always  fatal. 

Bad  prognostic  symptoms  are  continued  anorexia,  offensive  exhalations, 
much  anaemia,  great  prostration,  very  frequent,  feeble  and  irregular,  as 
well  as  very  infrequent,  pulse,  much  albuminuria,  deficient  urinary 
secretion,  great  glandular  enlargement  giving  tbe  appearance  of  "  bull- 
neck,"  extreme  adherence  of  the  false  membranes,  blackness  and  bleeding 
of  the  affected  surfaces  including  tlie  nasal  mucosa,  continued  high 
temperature,  and  persistent  vomiting.  With  most  of  these  symptoms 
there  is  the  greatest  danger  of  death  from  tbe  stress  of  tbe  poison ; 
and  we  must  never  forget  the  great  risk  of  almost  sudden  death  from 
cardiac  failure,  owing  to  paralysis  of  the  heart  or  to  a  combination 
of  this  condition  with  degeneration  of  its  walls.  The  constitutional 
symptoms  are  usually  most  prominent  when  the  local  mischief  is  severe, 
but  there  are  many  fatal  cases  with  but  slight  and  even  indefinite 
pharyngeal  affections  and  no  respiratory  trouble. 

Of  good  prognosis,  very  generally  speaking,  is  the  limitation  of  the  local 
process  to  the  tonsils  or  to  the  tonsils  and  uvula,  and  the  whiter  and 
the  less  adherent  the  membrane  the  better  the  forecast.  We  have  seen, 
however,  that  a  whitish  exudation,  overlying  the  tonsils  alone  and  but 
slightly  adherent,  is  not  necessarily  diphtheritic.  Moderate  frequency 
and  good  quality  of  pulse,  slight  malaise  and  prostration,  improvement 
of  the  faucial  condition  after  four  or  five  days,  and  but  slight  lesion  of 
the  surfaces  after  the  membrane  has  disappeared,  are  all  more  or  less 
favourable  symptoms.  But  until  complete  convalescence  be  established 
our  prognosis,  even  in  the  apparently  mildest  cases,  must  always  be 
expressly  guarded ;  for,  besides  the  late  onset  of  cardiac  and  other 
paralysis,  all  the  severest  symptoms  of  the  disease  may  follow  after  a 
seemingly  favourable  course  of  several  days. 

Treatment. — In  all  cases  strict  confinement  to  bed  in  a  well-ventilated 
room,  or  preferably  in  two  rooms  alternately,  with  a  temperature  not 
under  650  F.,  is  to  be  enjoined.  If  there  be  any  respiratory  trouble  the 
bed  should  be  closed  in  by  a  tent,  and  a  steam-kettle  kept  constantly 
in  action.  Food  should  be  given  frequently  in  small  quantities.  In 
many  cases,  whether  there  be  palatal  paralysis  or  not,  pultaceous  material 
is  more  easily  swallowed  than  liquid.  Milk  puddings,  meat-juice  of 
various  kinds,  beaten-up  eggs  or  pounded  meat  are  each  useful  in 
certain    cases.      When    food   is   refused   owing  to    faucial    swelling  or 


1/4  ACUTE  FEBRILE  DISEASES. 

pain  or  to  the  apathy  and  anorexia  which  are  so  frequent,  or  when,  if 
swallowed,  it  enters  the  larynx,  forced  feeding  with  the  nasal  tube,  as 
recommended  by  Scott  Battams,  is  to  be  instituted.  A  soft  catheter 
fixed  to  a  glass  syringe  is  passed  through  the  nose  into  the  oesophagus, 
and  the  food  slowly  injected  at  frequent  intervals.  Stimulants  are 
required  according  to  the  cardiac  indications  which  are  mostly  present 
in  some  degree  in  diphtheria,  and  may  be  prescribed  as  brandy,  or  as 
the  tincture  of  cinchona,  ammoniated  quinine,  or  the  aromatic  spirit  of 
ammonia.  Quinine  in  doses  of  not  less  than  one  grain  for  the  youngest 
child  may  be  given  three  or  four  times  a  day,  but  its  value  is  very 
questionable.     In  convalescence  arsenic  and  iron  are  decidedly  useful. 

Considering  that  diphtheria  is  in  all  probability  the  result  of  local 
inoculation  with  the  products  of  a  specifically  pathogenic  bacillus,  the 
question  of  local  treatment  is  of  great  importance ;  but,  as  it  seems  equally 
probable  that  the  locally  generated  poison  is  rapidly  absorbed  and 
diffused,  there  is  perhaps  but  little  hope  that  any  application  to  the 
diseased  surface  or  destruction  of  the  false  membranes  can  much  affect 
the  course  of  the  disease.  Few  cases  are  seen  early  enough  to  render 
such  a  result  even  prima  facie  probable.  But,  not  only  in  quite  early 
cases  but  also  in  all  others,  I  believe  that  every  possible  effort  should  be 
made  in  this  direction,  in  spite  of  the  questionable  success  that  has 
followed  on  the  practice.  By  thoroughly  and  frequently  cleansing  the 
fauces  and  nostrils  with  some  antiseptic  solution  we  may  not  only  relieve 
discomfort,  assist  deglutition  and  breathing,  and  limit  the  hurtful  effects 
on  the  respiratory  tract  of  infective  inhalation,  but  also  may  lessen  or 
prevent  the  further  development  of  the  rapidly  absorbable  poison,  how- 
ever powerless  we  may  be  in  antagonizing  its  action  after  absorption.  With 
these  objects  the  fauces  should  in  every  case  be  thoroughly  syringed  or 
swabbed  out  (swabbing  being  preferable  when  practicable,  as  it  usually 
is  with  skilled  assistance)  with  the  solution  of  chlorinated  soda  (i  part 
in  20  of  water)  or  with  Condy's  fluid  (1  in  40) ;  and,  after  the  removal 
of  the  false  membranes,  as  far  as  possible  without  force,  all  attainable 
surfaces  should  be  painted  over  with  the  glycerine  of  carbolic  acid  or  of 
borax,  or  brushed  over  with  a  solution  of  silver  nitrate  (15  grains  to  the 
ounce),  or  of  zinc  chloride.  Subsequently  the  syringing  or  swabbing 
may  be  repeated  every  three  or  four  hours,  if  the  exudation  should 
reappear,  until  the  local  trouble  subsides ;  and  afterwards  less  frequently 
until  the  fauces  take  on  their  normal  appearance.  A  steam-kettle  with 
a  2  per  cent,  solution  of  carbolic  acid  should  be  kept  in  continuous  use. 
The  nose  should  be  similarly  syringed  out  with  the  chlorinated  soda 
or  Condy's  solution  whenever  nasal  trouble  occurs,  or  the  irrigating  tube, 
fixed  to  a  receptacle  placed  above  the  patient's  head,  may  be  inserted 
into  one  nostril  and  a  pint  or  so  of  the  fluid  allowed  to  run  through  to 


DIPHTHERIA.  175 

the  other  nostril,  the  head  being  bent  forwards.  I  have  not  had  much 
experience  in  my  cases  of  the  action  of  papain  as  a  solvent  of  the  false 
membranes,  but,  as  far  as  I  know  and  can  learn,  its  use  is  unsatisfactory. 
An  alkaline  spray  kept  constantly  at  work,  or  used  for  several  minutes 
every  half  hour,  has  seemed  of  benefit  in  some  cases,  preparing  the  parts 
for  antiseptic  applications.  Dr.  Lewis  Smith  recommends  the  use  of 
such  a  spray,  consisting  of  2  drachms  each  of  eucalyptus  oil  and  sodium 
bicarbonate,  1  drachm  of  sodium  benzoate,  and  2  ounces  of  glycerine  to 
a  pint  of  lime-water. 

In  the  numerous  cases  undistinguished  by  definite  membrane,  where 
early  diagnosis  from  follicular  or  other  tonsillitis  is  not  possible  and 
especially  where  there  are  concurrent  cases  of  faucial  or  laryngeal  ill- 
ness, or  in  epidemic  times,  one  thorough  application  of  solution  of 
silver  nitrate,  followed  by  frequent  use  of  a  milder  antiseptic  lotion  or 
spray,  may  be  reasonably  recommended.  Cleansing  with  antiseptics  is 
especially  indicated  when  there  is  any  hypersemic  or  ulcerative  condition 
of  the  fauces  or  nose,  which,  as  we  have  seen,  is  a  predisponent  to  diph- 
theritic infection.  Of  this  both  scarlatina,  measles,  and  tonsillitis  furnish 
good  examples. 

The  treatment  of  diphtheria  advocated  by  Seibert  of  New  York, 
consisting  in  deep  injection  of  freshly-prepared  chlorine  water  into  the 
submucous  tissue  of  the  affected  parts  by  means  of  a  many-pointed 
syringe,  appears  to  be  well  worthy  of  trial  in  quite  recent  cases. 

The  management  of  laryngeal  diphtheria  is  mentioned  under  the 
heading  of  laryngitis.  For  full  practical  directions  I  would  refer  the 
reader  to  surgical  works,  among  which  I  may  mention  the  excellent 
monograph  by  Mr.  E.  "W.  Parker.  I  am  on  the  whole  an  advocate  for 
operation  by  tracheotomy  in  diphtheria,  whenever  the  marked  symptoms 
of  mechanical  obstruction  to  breathing,  such  as  indrawing  of  the  soft 
parts  of  the  thorax  and  throwing  back  of  the  head,  are  present,  and 
especially  when  there  is  inspiratory  intermission  of  the  pulse ;  and  this 
in  spite  of  the  few  cases  presumably  saved  thereby.  Early  tracheotomy 
in  children  over  three  years  old,  besides  preventing  the  suffocation  which 
might  soon  imperiously  demand  it,  may  lessen  exhaustion  and  thus 
favour  natural  recovery";  and  is  in  my  opinion  guiltless  of  the  broncho- 
pneumonia so  often  ascribed  to  it.  Broncho-pneumonia  whether  due 
to  spreading  of  the  inflammatory  process  or,  in  true  diphtheria,  to 
infective  inhalation,  occurs  not  only  in  membranous  laryngitis  but  also 
in  purely  faucial  or  nasal  cases,  and  is  quite  as  frequent  in  cases  of 
laryngitis  which  die  without  tracheotomy  as  in  those  which  are  relieved 
by  that  operation.  In  view  of  the  probably  evil  effects  of  constant 
inhalation  of  air  which  has  passed  over  the  diseased  naso-pharynx,  trache- 
otomy seems  preferable  to  intubation  in  all  cases  of  true  diphtheria. 


176  ACUTE  FEBRILE  DISEASES. 

In  the  extreme  prostration  and  collapse  which  usually  herald  death 
we  are  probably  helpless.  Alcohol  will  already  have  been  given  up  to 
its  full  limit  as  a  stimulant,  and  large  doses  are  rapidly  narcotic.  Musk 
in  doses  of  five  grains  placed  far  back  on  the  tongue  is  well  spoken  of 
by  some,  and  Henoch  faintly  recommends  the  trial  of  subcutaneous 
injections  of  strychnia. 

In  paralysis  of  all  kinds  rest  is  of  great  importance  until  complete 
recovery  is  attained,  in  view  of  the  possibility  of  heart  failure  ;  and, 
when  improvement  is  delayed  or  there  is  distinct  weakness  of  the 
respiratory  muscles,  strychnia  injections,  as  advised  by  Henoch  and 
according  to  some  experience  of  my  own,  may  be  at  least  safely  tried, 
beginning  with  a  daily  dose  of  -g-  grain  for  children  about  three  years 
old,  with  gradual  increase  up  to  double  the  original  quantity.  Paralyses 
other  than  cardiac  or  respiratory  usually  recover  completely,  sooner  or 
later,  without  any  special  treatment. 

Diphtheritic  cases  should  be  kept  continually  in  bed  until  the  dis- 
appearance of  all  symptoms  of  whatever  kind,  and  for  a  week  after  the 
cardiac  sound  and  rhythm  have  returned  to  the  normal,  even  if  other- 
wise completely  well. 

Attendants  on  the  sick  should  be  instructed  to  observe  strictly  the 
ordinary  rules  of  cleanliness  in  dealing  with  infectious  diseases,  to 
thoroughly  wash  their  hands  after  touching  the  patients,  to  avoid  as 
much  as  possible  taking  their  breath,  and  to  at  once  remove  all 
particles  of  matter  which  may  light  upon  them  from  the  mouth  or 
tracheotomy  wound.  Mr.  Parker  advises  that  all  the  inmates  of  a 
house  where  diphtheria  exists  should  frequently  rinse  out  their  mouth 
with  Condy's  fluid  and  similarly  brush  their  teeth  thoroughly  before 
going  to  bed ;  and  that  the  fauces  of  young  children  should  be  daily 
swabbed  with  glycerin  of  boracic  acid.  All  excretions  from  the  patient 
should  be  received  into  vessels  containing  a  strong  solution  of  carbolic 
acid  or  of  corrosive  sublimate  (1-500),  and  all  soiled  linen  should  be 
soaked  in  corrosive  sublimate  of  half  the  above  strength  before  being 
Avashed.  The  room  should  be  thoroughly  disinfected  after  the  illness. 
Patients  may  be  regarded  as  non-infective  after  a  week  from  the  dis- 
appearance of  all  local  symptoms ;  but,  on  account  of  the  necessity,  for 
their  own  sakes,  of  confining  them  to  the  house  for  at  least  three  more 
weeks,  it  is  well  to  continue  isolation  and  defer  local  disinfection  until 
complete  recovery  be  established. 


SCARLATINA.  1 77 


CHAPTER    III. 

SCARLATINA. 

The  following  remarks  are  intended  mainly  as  a  practical  comment  on 
some  of  the  chief  clinical  points  of  this  affection.  A  detailed  description 
of  scarlatina  and  its  complications  is  beyond  the  scope  of  this  work,  and 
if  there  he  room,  as  I  think  there  is,  for  yet  another  essay  on  this  subject, 
those  only  could  write  it  usefully  who  have  had  special  hospital  experience 
of  some  thousands  of  cases. 

From  one  point  of  view,  and  that  a  very  practical  one,  scarlatina  may 
be  regarded  as  an  infective  form  of  sore  throat,  the  diagnosis  of  which  is 
usually  difficult  and  sometimes  impossible  until  the  generally  characteristic 
rash  appears  in  from  about  twenty-four  to  forty-eight  hours  after  the  onset 
of  the  illness,  or,  in  some  cases,  until  the  almost  pathognomonic  desquama- 
tion sets  in  either  late  in  the  fever  or  after  its  subsidence.  It  were  well, 
indeed,  if  every  suddenly  occurring  pharyngitis  with  tonsillar  involve- 
ment, especially  in  childhood,  and  whether  marked  by  swelling  only, 
by  diffused  redness  with  swelling  or  by  exudative  tonsillitis,  patchy  or 
confluent,  were  suspected  as  scarlatinous  until  further  observation  have 
established  a  definite  diagnosis.  I  have  so  often  found  my  own  and 
others'  provisional  diagnosis  of  "follicular"  or  of  "herpetic"  tonsillitis, 
or  indeed  of  diphtheria,  completely  falsified  by  the  rash,  the  desquamation 
or,  sometimes,  the  dropsy  of  scarlatina  that  I  would  record  a  practical 
warning  against  reliance  on  any  descriptions  of  the  so-called  "typical" 
scarlatina  throat  which,  except  for  the  purpose  of  satisfying  some 
examiners,  are  apt  to  be  very  misleading.  The  deep-red  colouration 
with  swelling  of  the  pharnygeal  mucosa,  so  common  at  the  outset  and 
through  the  course  of  most  attacks  of  scarlatina  even  in  its  milder  forms, 
is,  however,  a  valuable  diagnostic  aid  when  we  have  to  pronounce  on  the 
probable  nature  of  an  ill-defined  eruption. 

The  occurrence  of  latent  scarlatina,  or  sore  throat  which  may  be  slight 
and  apparently  simple  without  observed  rash,  is  too  often  ignored  in 
practice,  although  alluded  to  by  several  and  strongly  insisted  on  by  Collie 
and  others.  It  is  not  perhaps  of  much  importance  to  inquire  whether  or 
no  there  is  always  a  rash  in  scarlatina.  The  rash  is  certainly  sometimes 
very  evanescent,  appearing  and  almost  disappearing  in  the  course  of  one 
day  or  night,  and  in  the  latter  case  is  often  overlooked  and  always  diffi- 
cult of  recognition.  I  have  seen  several  cases  of  undoubted  scarlatinous 
sore  throat,  as  evidenced  by  concurrence  -with  other  and  ordinary  cases, 

M 


178  ACUTE  FEBRILE  DISEASES. 

by  desquamation,  or  by  renal  sequelae,  where  no  rash  was  revealed  to 
repeated  and  careful  observation,  and  with  no  distinctive  appearance  of 
the  fauces.  A  similar  absence  of  observed  rash  may  occur  in  scarlatinous 
ulceration  of  one  or  both  tonsils,  and  also  in  cases  where  there  is  a  ton- 
sillar exudation  indistinguishable  at  first  sight  from  diphtheritic  affection. 
In  connection  with  this  we  must  remember  that  persons  who  have  had 
scarlet  fever,  as  well  as  some  who  have  not,  are  liable  to  sore  throat  of 
indifferent  appearance,  without  any  other  distinctive  symptom,  when 
exposed  to  the  contagion  of  scarlet  fever ;  and  that  such  cases  may  infect 
others  with  the  ordinary  form  of  the  disease.  I  am  well  convinced  of 
this  fact  from  personal  observation. 

Symptoms. — Scarlatina  usually  begins  with  a  sore  throat  accompanied 
for  the  most  part  by  enlargement  of  the  cervical  and  submaxillary  glands  ; 
and  vomiting,  rare  in  adults,  occurs  in  an  immense  majority  of  cases  in 
childhood,  being  far  more  frequent  as  an  initial  symptom  than  in  any 
other  of  the  acute  febrile  diseases.  There  are  also  as  a  rule  headache, 
very  frequent  pulse  and  pains  in  the  limbs  with  shivering,  and  sometimes 
there  is  diarrhoea.  Convulsions  occasionally  take  place  at  the  outset. 
The  temperature  may  rise  to  1040  or  over,  even  in  favourable  cases  and 
quite  at  the  beginning,  or  may  be  as  low  as  ioo°,  and  I  have  seen 
several  instances  of  a  persistently  normal  temperature  after  the  second 
day  in  cases  where  the  rash  appeared  after  an  erroneous  or  deferred 
diagnosis.  As  a  rule,  however,  the  temperature  and  other  febrile  symp- 
toms are  in  proportion  to  the  extent  of  the  rash  and  the  severity  of  the 
sore  throat.  The  temperature  is  usually  highest  at  the  acme  and  subsides 
generally  with  the  fading  of  the  eruption,  differing  herein  from  the  fever 
of  measles  which  generally  falls  suddenly  very  soon  after  the  rash  has 
reached  its  height.  In  very  severe  cases  of  scarlatina  the  temperature 
may  rise  higher  than  in  almost  any  other  fever,  even  no°  being  occa- 
sionally registered.  When  the  temperature  remains  up  after  the  rash 
has  disappeared  there  is  probably  severe  faucial  inflammation  or  one  or 
more  of  the  following  complications  : — glandular  suppuration,  cervical 
cellulitis  (which  is  very  dangerous),  otitis,  simple  or  occasionally  purulent 
synovitis,  pleurisy,  pericarditis  or  endocarditis,  or  some  acute  lung-trouble, 
especially  broncho-pneumonia, — most  of  which  may  be  demonstrated  or 
suspected  from  their  proper  signs  or  symptoms. 

The  rash  may  deviate  from  the  usual  type  in  being  blotchy,  papular, 
slightly  vesicular  and  occasionally  minutely  hsemorrhagic  in  some  parts, 
without  necessarily  serious  significance ;  but  as  a  ride  the  severity  of  the 
attack  is  directly  in  proportion  to  the  darkness  of  the  eruption's  hue. 
An  extensive  and  fatal  kind  of  purpura,  of  which  I  have  seen  one  in- 
stance and  others  are  recorded  by  Henoch  under  the  name  of  "  purpura 
fulminans,"  must,  I  think,  be  regarded  as  in  all  probability  an  occasional 


SCARLATINA.  1 79 

and  immediate  sequela  or  accompaniment  of  scarlatina.  These  hemor- 
rhagic patches  are  strictly  cutaneous,  not  involving  mucous  membrane  or 
internal  organs,  and  very  tender  to  the  touch.  More  frequent  and  far 
less  grave  are  attacks  of  ordinary  painless  purpura  a  few  weeks  after 
scarlatina,  with  or  without  mucous  haemorrhages,  and  not  associated 
with  fever. 

In  cases  of  doubtful  distinction  from  measles  it  is  well  to  remember 
that  the  scarlatinal  rash  is  not  characteristically  punctate  on  the  face, 
but  rather  a  bright  blush  on  forehead  and  cheeks ;  and  that  the  skin  of 
the  nose  and  its  neighbourhood  and  round  the  mouth  is  usually  pale. 

The  throat  appearances,  as  I  have  said,  vary  much.  There  may  be  only 
pharyngitis  of  varying  degrees  of  severity,  without  breach  of  surface,  the 
whole  pharynx  with  the  tonsils  being  often  much  swollen  and  injected, 
and  swallowing  more  or  less  impeded.  More  often  there  is  marked  ton- 
sillitis with  "follicular"  exudation  or  ulceration;  or  the  whole  of  one  or 
both  tonsils  may  be  covered  with  a  dirty  white  or  yellowish  pellicle  often 
mistaken  as  diphtheritic,  but  leaving  a  more  or  less  excavated  ulcer  on 
removal.  In  some  severe  cases  after  three  or  four  days  a  condition,  often 
indistinguishable  from  diphtheria,  is  seen  where  both  tonsils  are  covered 
with  a  membranous-looking  deposit,  on  the  removal  of  which,  however, 
extensive  subjacent  ulceration  is  frequently  found.  With  this  there  may 
be  excessive  pharyngeal  swelling  and  purulent  or  hsemorrhagic  discharge 
from  the  nose,  and  glandular  and  cellular  inflammation  and  abscesses 
may  ensue  with  extensive  gangrene  and  sloughing,  both  internal  and 
external.  This  condition,  though  frequently  regarded  as  diphtheria  super- 
vening on  scarlatina,  is  probably  to  be  distinguished  from  that  disease  by 
the  marked  ulceration  which  is  its  essential  feature,  and  by  being  neither 
accompanied  by  laryngitis  nor  followed  by  paralysis  on  recovery. 

True  diphtheria,  however,  with  all  its  characteristic  marks  and  in 
both  its  pharyngeal,  nasal  and  laryngeal  forms,  frequently  follows  on 
scarlatina,  and  not  alone  in  hospitals  where  both  diseases  are  admitted ; 
this  association  being  probably  explicable  by  a  predisposition  of  the 
injured  scarlatinous  throat  to  receive  the  diphtheritic  germ.  A  still 
closer  connexion  between  these  two  diseases  is,  moreover,  hinted  at  by  the 
occasional  concurrence  in  the  same  house  of  ordinary  scarlatina  and  what 
seems  to  be  diphtheria,  of  which  I  have  seen  some  examples.  The  whole 
question  involved  here  is  as  obscure  as  it  is  important,  and  demands 
further  experimental  and  clinical  investigation.  Dr.  MacCombie  of  the 
South-Eastern  Fever  Hospital,  with  a  very  large  experience  of  scarlatina, 
speaks  of  frequent  idceration  of  the  fauces  in  children  during  the  acute 
stage  of  the  fever,  sometimes  ending  in  the  formation  of  membrane  on 
the  fauces  and  pharynx,  spreading  to  larynx  and  trachea,  and  mainly 
associated  with  ulceration  of  the  posterior  nares ;  and  further  tells  me 


l8o  ACUTE  FEBRILE  DISEASES. 

that  the  membranous  affections  of  fauces,  nares  and  larynx,  which  so- 
often  follow  on  scarlatina  after  some  interval,  are  practically  identical 
with  diphtheria,  both  in  their  course  and  sequelse. 

Nasal  and  vaginal  discharges  are  common  in  the  scarlatina  of  child- 
hood. Post-pharyngeal  abscess  occasionally  occurs  in  severe  cases,  and 
may  cause  not  only  dysphagia  but  also  marked  dyspnoea.  This  compli- 
cation must  always  be  looked  for,  especially  when  there  is  late  dysphagia 
or  dyspnoea,  and,  when  found,  relieved  by  prompt  operation.  Cancrum 
oris  is  sometimes  observed,  but  less  frequently  than  in  measles. 

In  some  cases,  styled  malignant,  the  stress  of  the  disease  is  highly 
dangerous  or  mortal  without  any  serious  local  symptoms.  Great  prostra- 
tion rapidly  ensues  on  perhaps  repeated  vomiting ;  the  pulse  is  very  weak,, 
frequent  and  irregular  ;  the  extremities  are  cold ;  the  rash  may  be  irre- 
gular or  perhaps  livid  or  may  never  appear ;  and  death,  preceded  by  coma 
and  occasionally  by  convulsions,  may  follow  in  from  twelve  hours  to  a 
day  or  two  after  the  onset  of  the  attack. 

Albuminuria  is  frequently  found  after  the  fever,  but  has  no  certain 
relation  to  the  severity  of  the  attack.  It  mostly  begins  in  the  third 
or  fourth  week,  though  sometimes  much  earlier,  and  generally  lasts 
from  a  few  days  to  two  or  three  weeks.  It  is  occasionally  accompanied 
by  hsematuria,  the  presence  of  renal  casts  and  dropsy,  vomiting,  and 
other  clinical  symptoms  of  acute  nephritis.  A  slight  amount  of  albu- 
men may  also  be  found,  without  other  symptoms,  during  the  febrile 
attack,  and  is  then  probably  of  no  more  significance  than  that  which 
occurs  in  many  febrile  diseases.  In  severe  cases,  however,  there  may  be 
much  albuminuria  in  the  first  week.  The  true  nephritis  of  scarlet  fever 
is  part  of  the  poisonous  effects  of  the  contagium  and  certainly,  at  least 
in  many  instances,  quite  unconnected  with  chill.  Frequent  examination 
for  albuminuria  throughout  the  illness  and  for  at  least  three  weeks  after 
recovery  is  necessary  for  purposes  of  treatment,  for  this  affection  is 
occasionally  one  of  the  most  dangerous  phenomena  of  the  disease, 
involving  the  risk  of  heart  failure,  uraemia,  and  extensive  pulmonary 
oedema.  Absence  of  albumen,  when  dropsy  and  oliguria  are  present,  does 
not  exclude  the  diagnosis  of  nephritis.  There  is  much  variety,  more- 
over, in  the  daily  amount  of  albumen  in  many  cases.  It  is  very  common 
to  find  marked  albuminuria  for  the  first  time  when  the  patient  is  allowed 
to  get  up,  its  previous  absence  having  been  established  by  repeated 
examination.  This  affection  usually  lasts  some  weeks,  but  sometimes 
for  many  months,  and  in  a  minority  of  cases  is  chronic  or  recurrent 
with  slight  or  undiscoverable  exciting  causes.  Uraemic  convulsions  are, 
according  to  Dr.  MacCombie,  more  frequent  in  the  nephritis  of  child- 
hood than  of  adults. 

Pains  in  the  joints  and  limbs  are  common  about  the  end  of  the  first 


SCARLATINA.  I  8  I 

"week  or  earlier,  and  usually  last  but  a  few  days.  Articular  pain  with 
some  effusion  is,  moreover,  apt  to  occur  in  the  third  week  and  is  generally 
known  as  "  scarlatinal  rheumatism."  Dr.  MacCombie  informs  me  that 
this  is  usually  associated  with  albuminuria,  is  very  intractable,  lasting 
several  weeks,  is  prominently  characterised  by  fibrous  thickening  of  the 
tissues  round  the  joints,  and  often  leads  to  pronounced  stiffness.  My  own 
much  smaller  experience  of  scarlet  fever  quite  bears  out  this  description 
of  the  joint  appearances ;  and  from  this,  as  well  as  the  great  rarity  of 
the  sweatings,  heart  troubles,  and  other  incidents  of  acute  rheumatism, 
and  from  the  smaller  tendency  to  arthritic  metastasis,  I  am  of  opinion 
that  the  usual  designation  of  scarlatinal  rheumatism  is  misleading. 
Occasionally,  however,  without  doubt  the  two  diseases  may  be  closely 
connected  in  time.  I  have  more  than  once  seen  genuine  acute  rheu- 
matism in  known  rheumatic  subjects  follow  immediately  on  scarlatina. 

The  prognosis  in  any  case  of  scarlatina  should  always,  in  view  of  the 
many  possible  complications,  be  very  guarded,  and  no  definite  opinion 
should  be  given  of  its  ultimate  event  until  one  month  after  the  onset. 
In  epidemics  of  a  mild  and  non-complicated  character  the  prognosis  is 
pro  tanto  good,  and,  without  severe  throat  symptoms,  great  prostration 
or  continuously  high  temperature,  recovery  may  be  expected  in  a  great 
majority  of  cases  after  five  or  six  clays.  The  disease  is  commonest  in 
children  between  three  and  seven  years  old,  and  its  highest  fatality 
is  in  the  first  quinquennium  and  among  the  children  of  the  poor. 
Diarrhoea  is  often  seen  in  dangerous  cases,  and,  according  to  MacCombie, 
especially  in  weakly  children.  In  the  absence  of  other  severe  charac- 
teristics MacCombie  does  not  consider  that  diarrhoea  much  affects  the 
prognosis.  I  have  myself  seen  two  cases  of  scarlatina  in  infants 
with  severe  initial  diarrhoea  and  vomiting,  simulating  at  first  the  acute 
summer  diarrhoea  of  infancy,  which  were  otherwise  mild  and  made  a 
rapid  and  complete  recovery. 

A  very  frequent  pulse  is  the  rule  in  scarlatina,  even  in  some  quite 
mild  cases ;  but  an  irregular  pulse  is  in  my  experience  a  very  grave 
symptom  in  this  disease,  and  necessitates  a  very  cautious  prognosis. 

I  have  seen  a  few  indubitable  cases  of  true  relapse  of  typical  scarlet 
fever  after  about  a  week's  interval.  I  also  know  from  personal  obser- 
vation that  second  attacks  may  take  place,  and  have  no  doubt  of  the 
occurrence  of  third  attacks.  It  seems  certain  that  once-  or  twice-repeated 
attacks,  although  infrequent,  are  much  more  common  than  in  the  rest  of 
those  diseases  which  usually  confer  future  immunity  on  their  subjects. 
In  corroboration  of  these  statements  I  may  refer  to  several  cases  of 
indubitable  re-infection  within  short  periods,  reported  to  me  by  Mr. 
Scott  Battams  and  other  medical  friends,  where  definite  rash  and  defi- 
nite peeling  was  observed  in  both  attacks  ;  and  I  have  similar  information 


I  8  2  ACUTE  FEBRILE  DISEASES. 

from  officers  of  some  of  the  fever  hospitals.  Dr.  MacCombie  tells  me 
that  a  small  number  of  cases  of  scarlet  fever  are  re-infected  within  two 
months  of  the  commencement  of  the  first  attack.  He  has  seen  such 
cases  as  early  as  three  weeks  after  this  date,  but  states  that  they  usually 
take  place  after  an  interval  of  from  four  to  eight  or  ten  weeks.  "  These 
second  attacks,"  he  says,  "occur  in  patients  convalescing  from  typical 
attacks  of  scarlet  fever.  The  second  attack  is  sometimes  as  severe  as 
the  first,  and  is  followed  by  a  second  desquamation  and,  in  some  cases,, 
by  albuminuria." 

The  contagium  of  scarlet  fever  has  not  been  isolated,  but  is  probably 
admitted  into  the  body  through  the  faucial  mucosa.  The  poison  is 
undoubtedly  volatile  and  infective  at  some  distance,  but  is  seemingly 
far  less  widely  energetic  than  that  of  measles,  many  unprotected  children 
escaping  although  constantly  exposed  to  the  risk.  I  have  ascertained 
this  not  only  from  the  more  certain  and  wide  spread  of  measles  in 
hospital  wards,  but  also  from  many  single  cases  of  scarlatina  I  have 
known  in  the  crowded  families  of  the  poor.  There  is  much  evidence 
to  show  that  it  may  be  conveyed  in  milk  which  either  has  been  con- 
taminated by  persons  suffering  from  scarlatina  or  is  directly  infective 
as  coming  from  diseased  cows.  Although  there  is  a  lack  of  positive 
evidence  of  many  of  the  accepted  modes  of  spread,  and  of  the  duration 
of  vitality  in  the  poison  outside  the  body,  we  cannot  deny  that  the 
patient  is  infective  from  the  onset  of  the  disease,  or  possibly  from  the 
beginning  of  incubation,  until  desquamation  has  ceased.  The  period 
of  the  greatest  infectiveness  is,  I  believe,  from  the  beginning  to  the 
height  of  the  disease.  Of  the  great  infectiveness,  indeed,  by  means 
of  close  contact  in  the  very  earliest  stage,  experience  at  a  children's 
hospital  gives  ample  proof.  After  six  weeks  from  the  onset,  in  the 
majority  of  cases,  the  patient  may  be  regarded  as  harmless  to  others, 
provided  thorough  disinfection  of  the  body  has  been  observed,  and  no 
article  of  clothing  worn  for  a  week  before,  or,  say,  six  weeks  subsequent 
to  the  onset  of  the  illness,  be  still  in  use.  Every  object  with  which 
the  patient  has  been  in  contact  during  the  attack  should  be  destroyed,, 
if  possible. 

If  desquamation  be  continued  after  this  period,  as  it  not  infrequently 
is,  especially  on  the  feet,  there  is  probably  no  risk  of  infection,  provided 
a  course  of  hot  baths  and  antiseptic  washings  have  been  duly  followed  ;, 
but,  to  be  on  the  safe  side  and  in  view  of  some  reported  cases  which 
indicate  the  contrary  probability,  it  is  on  the  whole  advisable  to  isolate 
patients  until  all  desquamation  has  ceased.  The  incubative  period  of 
the  contagium  is  often  under  two  days,  as  I  have  repeatedly  observed, 
and  very  rarely  over  four  or  five.  Practically,  however,  a  complete 
week  should  pass  before  a  child  who  is  known  to  have  been  exposed 


SCARLATINA.  1 83 

to  the  poison  be  allowed  to  mingle  with  others,  and  his  person  and 
clothes  should  he  thoroughly  disinfected  before  his  release. 

In  ordinary  cases  treatment  is  simple.  Confinement  to  bed  for  three 
weeks  and  to  the  room  for  three  weeks  more,  a  milk  and  farinaceous  diet 
during  the  first  four  weeks,  occasional  purgatives  if  there  be  constipa- 
tion, and  daily  warm  baths,  with  all  precautions  against  chill,  during  the 
second  three  weeks  are  perhaps  all  that  is  necessary.  With  high  fever 
frequent  tepid  sponging  should  be  ordered,  and  in  extreme  cases  the 
cool  bath. 

When  the  throat  affection  is  troublesome  chlorate  of  potash  should  be 
given  internally,  and  the  fauces  should  be  brushed  over  with  glycerine  of 
borax  or  syringed  with  Condy's  fluid  (1  in  40).  In  all  cases  when  the 
fever  is  over,  and  especially  when  there  is  renal  trouble,  a  long  course  of 
iron  medicine  is  strongly  to  be  recommended.  When  there  are  symp- 
toms of  laryngitis  the  bed  should  be  inclosed  in  a  tent  into  which  steam 
should  constantly  play.  The  renal  affection  should  be  treated  according 
to  principles  elsewhere  laid  down,  and  all  other  complications  appro- 
priately dealt  with  by  medical  or  surgical  means.  Nephritis,  as  evidenced 
by  albuminuria  and  dropsy,  probably  affects  about  15  per  cent,  of  all 
cases.  It  might  be  well,  considering  that  the  kidneys  may  be  affected 
even  more  often  than  is  apparent,  to  diet  all  cases  of  scarlet  fever  on 
as  slightly  albuminous  food  as  possible  for  even  longer  than  the  above- 
mentioned  period  of  four  weeks. 

Forced  feeding  (by  means  of  the  nasal  tube,  if  necessary)  must  be 
employed  when  food  is  refused  or  swallowing  is  difficult,  and  free 
stimulation  with  carbonate  of  ammonia  or  repeated  small  doses  of 
alcohol  shoidd  be  resorted  to  when  indicated  by  general  depression  and 
feeble  or  frequent  heart  action.  Especially  is  such  stimulation  required 
when  there  is  irregularity  of  pulse.  Henoch  recommends  camphor  (grs. 
1-3)  as  a  valuable  stimulant  in  bad  cases,  or  a  hypodermic  injection  of 
sulphuric  ether  (min.  15)  when  swallowing  is  difficult. 

During  convalescence  and  until  the  end  of  the  sixth  week  the  patient, 
besides  being  regularly  bathed  in  hot  water  and  scrubbed  with  soap,  may 
be  daily  anointed  with  carbolic  oil ;  but,  when  perfect  isolation  has  been 
instituted,  this  process  is  unnecessary  until  the  time  comes  for  discharge 
from  confinement. 

It  has  been  frequently  urged  by  Dr.  J.  B.  Curgenven1  that,  by  the 
inunction  of  the  whole  body  with  eucalyptus  oil,  twice  daily  during  the 
first  three  days  of  an  attack  of  scarlatina,  and  nightly,  after  a  warm 
bath,  for  the  next  seven  days,  the  patient  is  rendered  free  from  the 
poison  and  is  not  in  a  condition  to  infect  others.  The  disinfectant,  he 
says,  should  also  be  sprinkled  over  the  bed  and  diffused  in  spray  about 

1  For  the  latest  exposition  of  his  views  see  the  Medical  Magazine  for  Feb.  1S93. 


I  84  ACUTE  FEBRILE  DISEASES. 

the  room.  He  advises  further  the  internal  administration  of  from  three 
to  six  drops  of  the  oil  three  times  a  day.  On  "behalf  of  this  plan  he 
claims  not  only  far  more  effective  prevention  of  the  spread  of  the  disease 
than  is  attained  "by  the  segregation  of  patients  in  fever  hospitals,  but 
also  a  high  degree  of  immunity  on  the  part  of  the  sufferers  themselves 
from  untoward  complications  and  sequelae.  It  is  only  by  extensive  ex- 
perience that  the  efficacy  of  this  treatment  can  be  established,  and  I  can 
say  nothing  on  the  matter  from  personal  knowledge.  From  the  evidence 
adduced,  hoAvever,  it  seems  to  me  that  a  sufficiently  good  case  has  been 
made  out  to  justify  an  ampler  trial  of  this  method,  in  view  especially  of 
the  unsatisfactory  results  obtained  by  observation  of  the  current  official 
regulations. 


CHAPTER    IV. 

MEASLES. 

Symptoms  and  Course. — This  disease  usually  begins  with  f  everishness, 
headache,  loss  of  appetite,  pricking  of  the  eyes,  lachrymation  and  photo- 
phobia, and  there  may  be  sneezing,  hoarseness,  cough  or  epistaxis.  On 
the  fourth  or  fifth  day,  rarely  later,  and  still  more  rarely  on  the  third 
day,  the  characteristic  rash  appears,  first  behind  the  ears  and  then  on  the 
forehead  close  to  the  scalp,  rapidly  occupying  the  rest  of  the  face,  and 
travelling  down  the  body.  It  is  at  its  height  both  in  colour  and  extent 
on  the  day  following  its  appearance,  and  on  the  next  day  or  next  but  one 
begins  to  fade  gradually  from  above  downwards.  On  the  appearance  of 
the  rash  the  early  symptoms  become  more  marked,  but  the  temperature 
tends  to  fall,  and  often  suddenly,  soon  after  the  rash  has  fully  developed. 
The  facial  eruption  is  important  when  the  previous  history  is  obscure 
and  doubt  may  exist  between  measles  and  scarlet  fever ;  for  the  region  of 
the  nose  is  almost  always  occupied  by  the  eruption  of  the  former,  and 
left  free  by  that  of  the  latter,  which  frequently,  indeed,  affects  the  face 
but  very  little  or  only  with  a  flush  of  indifferent  appearance. 

I  have  several  times  observed  the  remission  of  all  symptoms  and  the 
appearance  of  perfect  health  on  either  the  second  or  third  day  after  a  well- 
marked  febrile  invasion  with  rigors.  Not  seldom  there  is  a  papular  or 
blotchy  and  slightly  raised  rash  on  the  neck  or  forehead  at  the  very  outset, 
followed  on  the  fourth  day  by  the  typical  and  rapidly-spreading  eruption. 
Vomiting  is  not  very  rare  at  the  beginning,  though  much  less  frequent 
than  in  scarlatina,  and  initial  convulsions  occasionally  occur  in  young 


MEASLES.  185 

children  of  no  demonstrable  convulsive  tendency.  Sore  throat  is  some- 
times complained  of,  and,  if  examination  be  made  during  the  first  few 
days,  we  almost  invariably  find  a  patchy  redness  of  the  pharynx  and 
some  tonsillar  inflammation.  Laryngo-tracheal  catarrh  is  frequent  even 
at  the  outset.  I  have  often  seen  alarmingly  acute  laryngitis,  in  some 
instances  unaccompanied  by  other  catarrhal  symptoms,  which  was  none 
other  than  the  beginning  of  measles.  Such  initial  laryngitis,  albeit  of 
great  severity  and  suggestive  of  the  necessity  of  tracheotomy,  terminates 
as  a  rule  favourably,  and  often  subsides  with  the  developing  eruption. 
Operation  should  therefore  be  postponed  as  late  as  possible,  even  in 
severe  cases.  A  rapid  invasion  of  acute  laryngitis  should  always  suggest 
measles,  especially  in  the  absence  of  any  presumably  diphtheritic  appear- 
ance in  the  fauces. 

In  some  cases,  on  the  other  hand,  the  symptoms  of  the  pre-eruptive 
stage  are  so  indefinite  and  mild  that  no  diagnosis  of  their  true  nature  is 
possible ;  and  in  others  there  may  be  an  observed  absence  of  fever  until 
the  rash  appears,  Avhen  the  temperature  may  only  rise  two  or  three 
degrees.  Generally  speaking,  convalescence  from  all  symptoms  is  estab- 
lished in  about  a  week  from  the  day  of  invasion,  and  the  rash  completely 
disappears  and  the  patient  is  well  in  another  week.  Often,  and  especially 
when  the  rash  has  been  intense,  there  is  fine  branny  desquamation, 
mostly  on  the  face ;  but  this  is  by  no  means  the  rule,  and  in  the  majority 
of  cases  the  appearance  is  so  slight  as  easily  to  escape  notice.  It  usually 
begins  with  the  fading  of  the  rash.  The  last  stage  of  the  eruption  is  a 
pale  brownish-yellow  staining  of  the  skin,  the  result  of  small  extravasations 
of  altered  blood-pigment. 

Some  amount  of  bronchial  catarrh  evidenced  by  coarse  rhonchi  is  very 
often  present  even  when  the  cough  is  but  slight.  Catarrh  of  the  respira- 
tory tract  may  indeed  be  regarded  as  a  part  of  the  disease  even  still  more 
strictly  than  in  the  case  of  enteric  fever ;  and  acute  general  bronchitis 
and  broncho-pneumonia,  with  severe  symptoms,  are  excessively  frequent 
in  young  children,  especially  among  the  poor,  contributing  largely  to  the 
mortality  of  measles.  Acute  broncho-pneumonia  with  rapid  invasion  in 
a  previously  healthy  child  may  sometimes  indeed,  though  rarely,  be  the 
first  observed  phenomenon,  preceding  the  rash,  Avhich  may  then  be  slight 
and  indistinct. 

Diarrhoea  in  greater  or  less  degree,  probably  of  catarrhal  origin,  is 
very  common,  and  is  sometimes,  especially  in  summer-time,  of  serious 
import.1     When  it  is  protracted,  with  other  signs  of  imperfect  convales- 

1  Dr.  Hastings,  formerly  Resident  Medical  Officer  at  Shadwell  Hospital,  lays  stress 
on  the  importance  of  always  endeavouring  to  check  this  symptom  in  measles  at  once, 
and  on  the  frequent  difficulty  of  so  doing,  seeing  that  the  concurrence  of  bronchitis 
often  renders  opium  an  unsafe  remedy. 


I  86  ACUTE  FEBRILE  DISEASES. 

cence  and  notably  with  pulmonary  complication,  it  should  create  some 
suspicion  of  tubercular  disease  and  always  occasion  repeated  examination 
and  guarded  prognosis.  Even  in  severe  non-tubercular  cases  with  diarrhoea 
and  melsena  the  result  may  be  fatal,  and  all  degrees  of  entero-colitis  may 
be  found  post-mortem,  attended  sometimes  by  ulceration  chiefly  affecting 
the  solitary  glands. 

In  the  later  stages  of  measles  or  as  more  or  less  immediate  sequelae 
numerous  complications  may  occur.  Of  such  are  otitis  media  leading 
occasionally  to  cerebral  abscess,  ophthalmia,  inducing  sometimes  destruc- 
tive keratitis,  "noma"  of  the  cheek  or  vulva,  retro-pharyngeal  abscess, 
ekzematous  and  pustular  eruptions  of  the  skin,  stomatitis,  "  whooping " 
cough  and  membranous  laryngitis.  I  question  much  whether  all  cases 
of  these  last  two  affections  are  due  to  the  specific  poisons  of  pertussis 
and  diphtheria  respectively.  I  allude  again  to  the  relationship  between 
measles  and  spasmodic  cough  under  the  head  of  "  whooping-cough ; "  and, 
as  regards  the  membranous  laryngitis  which  may  be  found  either  at 
tracheotomy  or  after  death  or  may  very  rarely  be  established  by  ex- 
pectoration during  life,  my  own  experience  and  belief  correspond  with 
Henoch's  that  it  is  not  to  be  credited  to  the  diphtheritic  virus.  In 
such  cases  without  faucial  or  nasal  symptoms  the  membrane  is  found 
post-mortem  strictly  confined  to  the  respiratory  tract. 

Chronic  bronchitis,  broncho-pneumonia  long  in  resolution,  and,  though 
less  often,  empyema,  are  familiar  sequelae,  as  well  as  chronic  tuberculosis, 
especially  of  the  lungs  and  bronchial  glands.  Measles  indeed  seems  to 
prepare  the  ground  for  the  tubercular  process  in  a  large  proportion  of 
children  who  die  from  tuberculosis  in  its  various  forms,  whether  acute  or 
chronic ;  and  there  are  very  frequent  instances  of  previously  healthy 
children  in  whom  wasting  and  chronic  disorder,  both  in  the  pulmonary 
and  alimentary  tracts,  and  not  necessarily  tubercular,  seem  to  arise 
directly  out  of  severe  attacks  of  measles. 

True  pharyngeal  diphtheria  undoubtedly  occurs  sometimes  in  close 
association  with  measles,  especially  in  hospitals ;  but  the  connexion  is 
far  less  close  and  frequent  than  that  between  diphtheria  and  scarlatina. 

Paralytic  affections  of  various  kinds  seem  to  me  to  bear  a  certain 
relation  to  measles.  I  refer,  under  the  heading  of  nervous  disorders, 
to  some  examples  of  a  special  form  of  muscular  atrophy  Avith  this  con- 
nexion ;  and  have  seen,  besides  a  few  instances  of  Infantile  Paralysis, 
several  cases  of  nondescript  paresis  or  ataxia  of  the  legs,  apparently 
arising  directly  out  of  measles  and  with  difficulty  or  not  at  all  distin- 
guishable from  such  as  may  be  sequent  on  diphtheria.  I  have  notes, 
among  others,  of  a  case  of  a  girl  of  three,  previously  quite  healthy,  who 
three  days  after  the  onset  of  measles  lost  her  speech  and  all  power  over 
her  limbs,  and  had  much  difficulty  in  swallowing.     After  six  months  she 


MEASLES.  187 

had  lost  most  of  these  symptoms  hut  had  no  control  over  her  legs. 
Three  years  subsequently  the  walk  was  ataxic  and  the  speech  slow  and 
drawling.  There  was  no  wasting  nor  disturbance  of  sensibility,  and  the 
knee-jerks  and  electrical  reactions  were  normal.  Dr.  Barlow  has  called 
attention  to  a  myelitic  paralysis  following  measles,  and  I  feel  convinced 
that  the  influence  of  this  disease,  if  only  as  an  exciting  cause  of  neuro- 
muscular breakdown,  requires  further  observation. 

Various  epidemics  of  measles  have  variously  prominent  characteristics ; 
in  some,  acute  chest  affections  are  the  ride,  in  others,  severe  diarrhoea ; 
and  I  would  especially  mention  early  acute  laryngitis  and  ulcerative 
stomatitis  as  having  respectively  marked  by  their  frequency  two  con- 
siderable epidemics  of  which  I  had  experience  in  the  East  of  London. 
The  stomatitis  mainly  affected  the  tongue  and  gums,  and  in  many  cases 
there  was  an  apparently  "  diphtheritic  "  membrane  leaving  a  bloody  sur- 
face on  removal.     The  fauces  were  unaffected  except  by  hyperemia. 

The  rash  is  sometimes  in  quite  mild  cases  characterised  by  small 
extravasations,  and  more  extensive  purpura  may  occur  with  a  very 
severe  and  sometimes  even  a  fatal  result.  These  extravasations  may 
either  be  concurrent  with  the  ordinary  rash  or  appear  when  it  has  nearly 
faded.  I  have  seen  two  cases  of  somewhat  extensive  purpuric  eruption, 
appearing  late,  which  recovered  within  the  usual  time.  Of  a  form  of 
measles  mentioned  by  many,  where  the  whole  rash  from  the  first  is 
like  that  of  hemorrhagic  or  "  black  "  small-pox,  I  have  had  no  personal 
experience.  Considering  the  present  great  rarity  of  its  alleged  occurrence, 
it  seems  probable  that  Collie's  opinion  that  such  cases  are  mostly,  if  not 
always,  variolous  is  correct.  Collie  mentions  also  an  occasional  diagnostic 
difficulty  between  measles  and  small-pox,  when  the  rash  in  the  former  is 
at  first  sight  very  like  a  certain  initial  and  diffused  eruption  of  the  latter, 
especially  in  its  confluent  variety.  I  have  occasionally  met  with  this 
difficulty,  and  in  one  case,  during  a  time  of  small-pox,  where  the  rash 
seemed  to  me  unusually  prominent  and  hardish  to  the  feel  and  was 
unaccompanied  by  signs  distinctive  of  measles,  I  was  confident  in  a 
wrong  diagnosis.  But  Collie  points  out  that  there  is  almost  always  in 
such  cases  of  small-pox  a  character  of  shottiness  in  some  of  the  papules, 
and  that  the  surface  of  the  measles  face  is  usually  felt  to  be  much 
smoother ;  and  compares  the  small-pox  and  measles  skin,  as  regards 
touch,  to  corduroy  and  velvet  respectively.  I  do  not  think  that  the 
isolated  papules  which  sometimes  usher  in  the  rash  of  measles  should 
ever  cause  much  difficulty  of  distinction  from  the  early  eruption  of 
ordinary  small-pox,  for  they  are  never  of  shotty  character,  and  the  different 
course  of  the  early  fever  with  the  ingravescent  rash  in  the  two  diseases 
would  soon  clear  up  any  possible  doubt. 

I  shall  leave  the  matter  of  the  diagnosis  of  measles  from  scarlatina 


I  88  ACUTE  FEBRILE  DISEASES. 

and  so-called  "rubella"  to  be  inferred  from  the  general  consideration  of 
these  affections ;  and  would  only  remark  here  that,  however  observant 
and  experienced  a  man  may  be  with  regard  to  the  exanthemata,  a 
diagnosis  should  never  be  made  dogmatically  on  the  sole  basis  of  the 
rash,  which  is  in  no  disease  always  pathognomonic.  Innumerable  errors, 
mostly  avoidable,  are  made  from  neglect  of  this  warning,  and  when, 
as  may  be  the  case  in  any  exanthematous  affection,  the  eruption  is 
throughout  uncharacteristic,  or  is  never  observed  in  virtue  either  of  its 
evanescence  or  non-existence,  it  is  clear  that  too  much  reliance  on  erup- 
tive appearances  may  leave  us  helpless  or  cause  us  to  blunder  gravely. 

The  contagium  of  measles  has  not  been  isolated,  although  certain 
bodies  are  said  to  have  been  found  in  the  blood  and  expired  breath.  It 
is  probably  contained  in  the  breath  and  possibly  in  all  other  emanations 
from  the  body ;  is  certainly  most  active  from  the  outset  to  the  height 
of  the  disease ;  and  is,  with  the  possible  exception  of  that  of  influenza, 
more  energetic  than  any  other.  There  is  no  evidence  that  it  outlives  the 
symptoms,  although  there  is  some  that  its  activity  may  anticipate  them ; 
and  the  patients,  after  a  hot  bath  and  plentiful  scrubbing  and  disinfection 
of  all  clothes  which  they  may  have  worn  during  the  illness  or  a  fortnight 
previously,  may  certainly  be  pronounced  harmless  to  others  when  three 
weeks  have  passed  from  the  day  of  invasion  and  probably  as  soon  as  the 
rash  has  quite  vanished.1  If,  however,  they  be  still  desquamating,  or 
suffering  from  a  continuously  marked  chest  affection  with  any  rise  of 
temperature,  it  is  well  to  confine  them  longer  both  for  their  own  sake 
and  possibly  that  of  others.  We  have  no  certain  knowledge  as  to  the 
conveyance  of  the  contagium  by  clothes  or  by  unaffected  persons.  Our 
precautions,  therefore,  must  be  on  the  side  of  safety.  The  period  of 
incubation  is  generally  believed  to  be  about  ten  or  twelve  days  before 
the  invasion  symptoms.  On  some  occasions  at  Shadwell  we  have  been 
able  to  fix  on  eleven  days  with  considerable  accuracy,  and  in  several 
more  the  rash  of  measles  has  been  noticed  on  the  fifteenth  day  after  a 
short  exposure  to  infection  from  cases  which  have  been  discharged  from 
the  ward  immediately  on  discovery  of  the  eruption. 

Measles  may  undoubtedly  occur  twice,  even  during  childhood,  and 
a  second  attack  in  adult  life  is  not  uncommon.  True  relapses  of  all 
symptoms  within  a  week  or  so  of  convalescence  are  also,  though  rare, 
beyond  question.  For  further  details  as  to  the  course  of  measles,  its 
symptoms  and  its  varieties,  I  refer  to  the  larger  works. 

Treatment. — In  all  cases  the  chief  necessity  is  protection  from  chill 
and  everything  that  may  aggravate  the  respiratory  catarrh  which  forms 

1  Cases  have  been  frequently  sent  back  to  the  general  wards  from  the  "  Infectious 
Block"  at  Shadwell,  as  soon  as  the  rash  had  gone,  with  no  instance  of  spreading  of  the 
disease. 


RUBELLA.  189 

the  chief  element  in  the  immediate  gravity  of  the  disease.  This  is 
especially  necessary  in  children  under  three  years  of  age,  who,  however, 
frequently  die,  sooner  or  later,  in  spite  of  all  precautions.  Chest  and 
laryngeal  affections  and  all  important  complications  or  sequelae  are  to 
be  treated  on  the  lines  elsewhere  laid  down ;  but  slight  epistaxis,  slight 
cough  and  other  unimportant  symptoms  may  be  let  alone.  I  usually 
give  a  combination  of  carbonate  of  ammonia  and  compound  tincture 
of  camphor  for  a  very  troublesome  cough  in  ordinary  cases,  and  advise 
tepid  sponging,  when  the  fever  is  high,  with  due  precaution  against  chill. 
There  is  no  need  for  confining  to  bed  a  child  who  feels  well,  after  the 
temperature  lias  fallen  to  normal ;  but  he  should  be  kept  in  the  room 
for  a  week  longer  and  in  the  house  for  a  fortnight  more.  While  any 
cough  remains,  even  though  there  be  no  abnormal  physical  signs  in  the 
chest,  precautions  against  chill  should  be  continuous.  In  all  complicated 
cases  and  those  with  tubercular  tendencies  there  is  enhanced  necessity 
for  the  greatest  care. 

Considering  the  pulmonary  sequelae  and  their  encouragement  of  tuber- 
culosis, measles  is  ultimately  one  of  the  most  fatal  of  the  fevers  of  child- 
hood. Some  regulations  and,  perhaps,  hospital  accommodation  to  prevent 
its  spread  and  minimise  its  severity  seem  to  be  more  urgently  required, 
in  the  interests  of  children,  than  in  the  case  of  those  diseases  which 
are  already  dealt  with  in  London  by  the  government  institutions. 


CHAPTER    V. 

RUBELLA    (OR    "GERMAN    MEASLES  "). 

It  is  now  recognised  by  most  observers  that  an  exanthematic  contagious 
fever  of  short  duration,  with  a  rash  usually  resembling  that  of  measles 
but  sometimes  that  of  scarlatina,  occurs  from  time  to  time  both  in 
sporadic  and  epidemic  form ;  and  that  there  is  no  mutual  protectiveness 
between  this  fever  and  either  measles  or  scarlatina.  There  is,  how- 
ever, a  much  wider  discrepancy  in  almost  all  points  between  the  many 
descriptions  of  so-called  rubella,  published  by  observers  of  large  numbers 
of  cases  in  various  epidemics  and  in  different  countries,  than  obtains  in 
regard  to  the  definition  of  any  other  specific  fever.  This  discrepancy 
indeed  is  so  great  as  to  justify  the  statement  that  rubella,  apart  from 
the  doubtless  important,  though  not  crucial,  test  of  its  epidemic  occurrence 
among  those  who  have  previously  suffered  from  scarlatina  or  measles, 


190  ACUTE  FEBRILE  DISEASES. 

has  no  greater  mark  of  specificity  than  appertains  to  recognised  varieties 
of  these  two  diseases. 

It  is  especially  in  the  diagnosis  of  sporadic  cases  of  this  supposedly 
specific  disease  that  a  generally  insuperable  practical  difficulty  arises ; 
and  my  own  experience  and  careful  study  of  much  of  the  literature  of 
the  subject  forces  me  to  teach  that  such  a  diagnosis  should  never  be 
made  until  such  time  as  a  subsequent  series  of  like  instances  may  seem 
to  justify  it,  and  even  then  should  never  be  pronounced  at  the  outset 
of  any  individual  case.  If  rubella  be  a  specific  disease  it  certainly 
cannot  breed  scarlatina  or  measles ;  but  it  is  unquestionable  that  cases 
which  many  observers,  including  several  who  have  made  this  question 
a  special  study,  denominate  rubella  may,  and  often  do,  give  rise  to  ordinary 
scarlatina  or  ordinary  measles.  It  is  no  answer  to  those  who  are  fre- 
quently confronted  with  this  difficulty  and,  therefore,  provisionally  con- 
clude, as  I  do,  that  the  question  of  specificity  is  not  settled  and  that 
there  may  be  more  than  one  form  of  fever  included  under  the  title  of 
"rubella,"  to  adduce  the  frequent  variations  from  the  normal  type  in 
many  particulars  of  other  infectious  diseases.  For  it  must  appear  to 
any  careful  student  of  the  widely-varying  first-hand  accounts  of  rubella 
by  different  observers,  who  nevertheless  alike  entertain  no  doubt  of  its 
specificity  and  attribute  either  want  of  experience  or  reason  to  those 
who  do,  that  there  is  nothing  approaching  to  the  average  description  of 
a  clinical  type  disease  to  be  extracted  from  an  unprejudiced  collation 
of  the  most  important  authorities ;  and,  further,  that  what  some  writers 
regard  as  almost  pathognomonic  symptoms  are  stated  by  others  to  be 
very  exceptional.  Thus  many  observers  regard  enlargement  and  tender- 
ness of  the  cervical  glands,  especially  those  behind  the  sterno-mastoid 
and  in  the  post-aural  region,  as  almost  constant,  while  others  as  positively 
state  that  it  is  very  rare ;  and  there  is  no  general  consensus  about  the 
frequency  of  invasion  symptoms  before  the  rash,  the  prevalent  presence 
or  absence  of  coryzal  signs,  of  inflammatory  sore  throat,  of  complications, 
or  of  desquamation. 

Concerning  the  rash,  descriptions  differ  so  much  as  to  distribution, 
duration,  form  and  colour  that  it  may  be  fairly  said  to  be  of  no  diag- 
nostic value.  This,  indeed,  is  freely  confessed  by  many  who  regard 
rubella  as  one  and  indivisible.  Often  it  is  stated  to  be  indistinguishable 
from  the  rash  of  measles,  and  not  seldom  very  like  that  of  scarlatina, 
and  in  certain  instances  it  may  be  at  first  morbilliform  and  later  scarla- 
tiniform  in  appearance.  Each  observer,  having  diagnosed  any  given 
epidemic  illness  as  rubella,  naturally  regards  the  rash  and  other  symptoms 
that  he  has  himself  observed  as  characteristic  ;  and  it  can  scarcely  be 
denied,  judging  from  the  multifarious  literature  of  this  subject,  that  if 
there  be  one,  there  are  more  than  one  clinical  group  of  symptoms  which 


RUBELLA.  1 9  I 

equally  deserve  an  isolated  position.  It  must  be  added  that,  while  there 
is  a  general  belief  in  the  almost  uniform  mildness  of  ruhella,  some  teach 
that  it  is  often  severe  and  sometimes  fatal  from  laryngeal  and  pulmonary 
mischief ;  and,  although  most  regard  its  occurrence  as  protective  against 
a  second  attack,  some  urge  that  it  is  very  often  recurrent  and  may  affect 
one  individual  several  times.  The  different  statements  made  as  to 
the  period  of  incubation  are  of  less  weight  than  other  discrepancies  in 
connexion  with  the  question  of  specificity,  for  the  limits  of  this  period 
are  wide  enough,  as  far  as  any  certain  knowledge  goes,  in  most  recognised 
affections  of  this  class.  Such  limits  in  ruhella  are  said  to  be  from  a  few 
days  to  three  weeks,  most  authorities  fixing  about  the  same  period  as 
that  of  measles,  namely  about  a  fortnight  from  infection  to  eruption.  A 
Avell-marked  epidemic,  however  (whereof  I  had  some  knowledge  and  a 
full  first-hand  report),  which  seemed  to  correspond  very  closely  to  many 
descriptions  of  rubella,  was  certainly  not  scarlatina,  and  attacked  many 
who  had  very  recently  had  measles,  had  definitely  in  some  cases,  and 
probably  in  most,  an  incubation-period  of  not  more  than  five  days. 
From  Avhat  I  have  seen  myself  in  the  ordinary  course  of  practice  I  can 
say  but  little  regarding  extensive  epidemics  of  this  kind;  but  from 
certain  sporadic  cases  that  I  have  from  time  to  time  met  with  I  should 
be  inclined  to  regard  the  following  group  of  symptoms  occurring  epidemi- 
cally as  deserving  of  a  clinical  position  probably  separate  from  both 
measles  and  scarlatina : — Fever,  mild  and  of  from  one  to  three  or  four 
days'  duration,  a  measles-like  rash  from  the  beginning  of  symptoms,  and 
slight  or  marked  sore  throat,  with  or  without  swelling  of  the  cervical 
glands.  The  papules  of  the  rash  are  perhaps  smaller  and  tend  to  be 
more  confluent  in  places  than  those  of  ordinary  measles,  but  show  the 
same  order,  with  possibly  greater  rapidity,  of  progress  from  the  face  and 
neck  downwards.  I  have  also  sometimes  seen  isolated  cases  which 
answered  exactly  to  those  described  by  many  as  "  rubella  scarlatinosa," 
there  being  a  scarlatinous  rash,  with  some  fever,  illness  and  inflammatory 
sore  throat,  not  followed  by  desquamation.  Some  of  these  have  had 
considerable  coryza.  Again,  I  have  seen,  more  than  once,  several  cases,  in 
one  family  of  children,  of  a  rash  much  more  like  that  of  scarlatina  than 
of  measles,  preceded  by  half  a  day's  slight  feeling  of  malaise,  with 
no  sore  throat  or  other  complaint,  and  very  slight  pyrexia;;  the  rash 
beginning  on  the  face  and  progressing  over  the  body  in  a  downward 
direction,  the  face  being  clear  before  the  legs  were  affected,  and  all  signs 
disappearing  by  the  end  of  the  second  day.  In  one  set  of  three  cases  of 
this  kind  there  was  a  fortnight's  interval  between  the  appearance  of  the 
rash  in  each.  On  the  whole,  however,  I  personally  regard  as  rare  the 
occurrence  of  any  cases  which  suggest  the  diagnosis  of  rubella,  however 
described ;  and  the  mainly  negative  hospital  experience  of  my  own  for 


192  ACUTE  FEBRILE  DISEASES. 

many  years  in  this  respect  is  corroborated  by  that  of  several  of  our 
resident  medical  officers  at  Shadwell,  a  district  teeming  with  children. 
Mr.  Scott  Battams,  who  held  that  office  for  nine  years  and  saw  many 
thousands  of  casualty  cases  brought  for  all  kinds  of  acute  diseases,, 
including  innumerable  instances  of  scarlatina  and  measles,  was  never 
forced  to  the  diagnosis  of  rubella.  One  of  the  most  positive  assertors,1 
moreover,  of  the  specificity  of  rubella,  while  making  the  self-evident 
remark  that  "should  the  disease  preserve  a  typical  course  but  little 
difficulty  will  be  met  in  the  diagnosis,"  states  that  in  a  single  case  there 
is  no  positive  diagnostic  guide ;  and  similar  admissions  are  freely  made 
by  the  majority  of  authorities,  however  widely  they  may  differ  inter  se 
as  to  the  "  type  "  of  the  disease. 

Without  therefore  denying  the  probability  of  the  existence  of  some 
such  specific  disease  as  the  "  rubella "  of  many  authorities,  which  may 
conceivably  indeed  be  setiologically  one  in  spite  of  an  indescribable  and 
almost  limitless  variety  of  clinical  expressions,  I  feel  sure  that  as  a  matter 
of  practice  it  should  be  diagnosed  in  individual  cases  with  the  greatest 
hesitation,  and  that  we  are  rarely  justified  in  positively  excluding  both 
measles  and  scarlatina  in  any  isolated  case  of  supposed  rubella.  By  this 
precaution  we  may  be  saved  from  many  a  blunder  at  the  small  expense 
of  a  frank  confession  of  ignorance.  It  is  beyond  doubt  to  any  one  of 
experience  that  many  cases  of  afterwards  unquestionable  measles  or 
scarlatina  vary  so  much  from  the  "  type  "  or  prevalent  form  that  they 
can  only  be  rightly  judged  of  from  their  close  association  with  cases 
of  the  universally  recognised  type-disease ;  but  in  the  matter  of  rubella 
the  typical  image,  if  indeed  it  exist,  still  awaits  the  medical  artist  to 
liberate  it  from  its  conglomerate  matrix  of  clinical  material.  Its  alleged 
varieties  are  all  that  meet  the  eye. 

The  difficulties  of  diagnosis  will  probably  not  be  set  at  rest  without 
the  discovery  of  a  specific  organism,  of  which  criterion  of  individuality 
no  contagious  disease  stands  more  in  need  than  so-called  rubella.  Of 
the  theory  that  rubella  is  a  hybrid  between  scarlatina  and  measles  I  can 
but  say  that,  if  this  means  that  the  subject  is  infected  simultaneously 
by  the  two  poisons,  the  epidemic  occurrence  of  the  disease  is  not  thereby 
rationally  explained;  whereas,  if  the  term  "hybrid"  be  inaccurately 
predicated  of  the  hypothetical  germ  of  rubella  supposed  to  be  in  an 
imperfectly  differentiated  or  transitional  condition,  the  notion,  if  super- 
ficially plausible,  is  certainly  fanciful  and  unsupported  by  analogy,  either 
clinical  or  biological. 

Of  treatment  there  is  nothing  for  me  to  say.  In  my  own  experience 
only  ordinary  care  with  no  special  medication  has  been  indicated  in  any 
case  which  I  would  regard  as  neither  measles  nor  scarlatina,  or  in  which 
,    x  Dr.  Edwards  in  Keating's  Cyclopcedia  of  Diseases  of  Children,  s.  v.  "Rubella." 


CHICKEN-POX,  MUMPS  AND  INFLUENZA.  I  93 

I  practically  excluded  those  diseases  on  the  ground  of  an  epidemic  pre- 
valence of  an  exanthem  among  those  who  had  already  been  their  subjects. 
But  there  is  good  evidence  that  cases  of  a  serious  nature  occur  from  time 
to  time,  which  have  as  much  claim  as  the  milder  ones  to  be  regarded  as 
"  sui  generis,"  although  it  does  not  yet  appear  whether  they  belong  to 
the  same  or  a  different  category. 


CHAPTER  VI. 

CHICKEN-POX,    MUMPS    AND    INFLUENZA. 

Chicken-Pox  ( Varicella). 

On  this  exceedingly  common  disease,  which  is  mainly  incident  on  children 
from  one  to  ten  years  old,  I  have  little  comment  to  make,  and  shall  not 
attempt  more  than  a  brief  description,  with  cautions  as  to  diagnosis. 

The  affection  is  very  contagious,  its  poison  being  in  all  probability 
readily  air-borne  and  carried  also  in  clothing ;  its  fever  lasts  but  a  few 
days  and  is  usually  very  slight ;  and  recovery  is  for  the  most  part  com- 
plete without  sequelae.     Epidemic  prevalence  is  very  frequent. 

Although  as  yet  the  specificity  of  the  poison  of  chicken-pox  has  not 
been  micro-biologically  established,  we  are  justified  in  believing  in  its 
existence,  and  the  clinical  evidence  of  its  distinctness  from  that  of  small- 
pox is  overwhelming.  Nevertheless  there  are,  doubtless,  a  few  cases,  both 
in  children  and  sometimes  in  adults,  which  at  first  occasion  insuperable 
diagnostic  difficulty  even  to  expert  observers.  I  have  myself  known 
more  than  one  case  definitely  diagnosed  as  small-pox  by  men  who  have 
had  great  hospital  experience  of  that  disease,  but  whose  opinion  has 
been  subsequently  proved  erroneous,  not  only  by  the  course  of  the  indi- 
vidual case,  but  also  by  the  concomitance  in  the  patient's  family  of 
several  cases  of  typical  varicella. 

It  may  be  freely  conceded  to  the  few  authorities  who  may  still  regard 
these  two  diseases  as  due  to  one  and  the  same  poison  that,  at  least  clini- 
cally, it  is  absolutely  impossible  in  some  cases  to  differentiate  between 
varicella  and  that  modified  form  of  small-pox,  so  familiar  in  children 
during  epidemic  times,  which  is  known  by  the  title  of  varioloid. 

The  incubatory  stage  of  the  disease  may  be  practically  stated  as  from 
two  to  three  weeks,  although  some  observers  give  the  minimum  period 
as  eight  days.  In  my  experience  fourteen  or  fifteen  days  has  been  the 
most  frequent  period.     Whatever  slight  symptoms  of  illness  there  may 

N 


194  ACUTE  FEBRILE  DISEASES. 

sometimes  be  before  the  rash  appears  are  quite  indistinctive.  In  very 
rare  cases  there  is  premonitory  fever  of  considerable  severity.  I  have 
myself  seen  two  cases  where  the  characteristic  eruption  of  vesicles  was 
preceded  for  nearly  two  days  by  a  bright  red  rash  almost,  if  not  quite, 
indistinguishable  from  that  of  scarlatina.  In  both  these  cases  fever 
was  high  with  marked  illness,  and  the  varicellar  eruption  was  very 
profuse.  No  desquamation  ever  took  place  nor  was  there  any  sore 
throat.  As  is  well-known,  the  eruption  begins  as  small  red  spots,  slightly 
elevated,  which  in  the  course  of  a  few  hours  as  a  rule  become  vesicular. 
The  vesicles  sometimes  retain  a  surrounding  red  areola,  but  at  other 
times  this  is  absent,  causing  the  appearance  popularly  known  in  some 
districts  as  "glass-pox."  In  a  small  minority  of  cases,  otherwise  normal 
and  benign,  vesiculation  may  be  retarded,  certainly  for  many  hours  if  not 
for  a  whole  day,  and  these  are  the  instances  where  there  is  the  greatest 
difficulty  of  diagnosis  between  varicella  and  varioloid.  Successive  crops 
appear  during  two  or  three  days,  after  which  the  fever  falls  or  disappears 
and  the  skin  affection  begins  to  decline  with  drying  up  or  crusting  of 
the  vesicles.  Sometimes  the  vesicles  become  enlarged  and  show  a  slight 
depression  (or  "  umbilication  ")  in  the  centre.  The  larger  vesicles  and 
others  which  have  been  injured  by  scratching  or  otherwise  often  leave 
behind  them  a  persistent  round  white  cicatrix.  The  duration  of  the 
disease  until  the  falling  off  of  the  scabs  is  from  about  eight  to  eleven 
days.  The  eruption  may  occupy  the  whole  body  as  well  as  the  oral  and 
faucial  mucous  membranes,  and  usually  proceeds  from  above  downwards. 

In  some  cases,  otherwise  slight  and  ordinary,  some  of  the  vesicles  have 
purulent  contents. 

I  have  seen  a  few  cases  where  some  sore-throat  has  been  complained 
of,  with  signs  of  moderate  pharyngitis. 

There  is  a  form  of  varicella,  not  very  rarely  observed  since  attention 
was  first  called  to  it  by  Mr.  Hutchinson,  where  some  of  the  vesicles  enlarge 
and  ulcerate,  or  may  become  black  and  gangrenous  with  deep  ulcers  under- 
lying the  scabs.  This  process,  according  to  Dr.  Crocker,  does  not  always 
occupy  the  seat  of  the  varicella  vesicles,  but  may  attack  other  parts.  It 
would  appear  that  this  form  or  rather  complication  of  varicella  occurs 
especially,  if  not  entirely,  in  weakly  children  or  those  who  are  tubercular, 
and  should  scarcely  be  regarded  as  other  than  an  accidental  epi-pheno- 
menon.  In  its  graver  form  it  is  frequently  fatal,  especially,  if  not  always, 
in  tubercular  cases ;  but  in  its  lesser  degrees,  which  alone  can  be  con- 
sidered as  not  very  rare,  recovery  may  take  place  with  comparative 
frequency.  Continued  pustular  eruption  not  seldom,  and  pemphigus 
and  urticaria  sometimes,  are  met  with  as  sequels  of  varicella.  Very  occa- 
sionally acute  nephritis  follows  in  a  few  days  after  the  subsidence  of  the 
disease. 


CHICKEN-POX,  MUMPS  AND  INFLUENZA.  195 

It  is  unnecessary  to  dwell  on  the  differences  between  varicella  and 
ordinary  variola,  but  we  must  always  be  on  our  guard,  whether  in 
epidemic  times  or  not,  against  the  dangerous,  albeit  sometimes  unavoid- 
able, diagnostic  confusion  of  varicella  and  varioloid.  When  a  definite 
period  of  three  days'  prodromal  fever,  especially  with  back-ache  and  chill, 
has  existed,  we  must  not  diagnose  varicella,  however  characteristic  of  this 
affection  the  eruption  may  be,  but  isolate  the  patient  at  once  on  the 
suspicion  of  small-pox ;  if,  however,  as  is  by  no  means  very  rare  in  vario- 
loid, there  be  no  clear  period  of  symptomatic  invasion,  but  slight  illness 
and  fever  only  and  no  pustulation,  we  have  nothing  to  depend  on  for 
distinction  from  varicella  but  the  possibly  shotty  feel  of  the  papules. 
If  well-marked  this  is  a  valuable  positive  sign  as  a  rule ;  but  I  have 
observed  it  at  least  once  in  true  varicella,  with  much  retarded  vesiculation, 
where  it  deceived  not  only  myself  and  several  others,  but  also  a  careful 
connoisseur  of  small-pox  of  many  years'  hospital  experience.  As  regards 
the  distribution  of  the  eruption  in  these  affections  it  has  been  observed 
by  Dr.  MacCombie  and  others  that  in  small-pox  the  extremities,  in 
chicken-pox  the  trunk,  is  most  affected. 

In  spite  of  the  almost  constant  benignity  of  chicken-pox  all  patients 
should  be  isolated  if  for  no  other  reason  than  the  possibility  of  the  rare 
and  grave  complication  above  noticed.  No  special  treatment  is  required 
in  the  vast  majority  of  cases.  There  is  no  reason  to  believe  that  the 
patient  is  infective  to  others  after  the  disappearance  of  all  scabs. 

Mumps  {Contagious  Parotiditis). 

Of  this  disease  with  its  well-known  characteristics  my  experience  has 
furnished  me  with  no  grounds  for  comment  on  the  classical  description 
given  in  the  text-books.  The  diagnosis  is  rarely  difficult,  except  in  cases 
where  the  swelling  is  but  indistinctly  localised  in  the  parotid  region  or 
more  especially  involves  the  submaxillary  glands,  and  in  those  where  the 
parotid  swelling  remains  unilateral  for  more  than  two  or  three  days. 
These  difficulties  are  of  course  more  prominent  if  the  case  be  a  sporadic 
one,  or  the  first  encountered  in  a  time  of  epidemic. 

I  have  seen  cases  of  lymphatic  glandular  abscesses  which  have  been 
at  first  sight  taken  for  mumps,  as  well  as  some  of  swelling  in  the 
parotid  and  submaxillary  regions  which  were  secondary  to  periostitis 
of  the  jaw. 

It  is  frequent  for  the  swelling  of  one  side  to  precede  by  a  day  or  two 
that  of  the  other,  and  not  rare  for  the  submaxillary  glands  and  even  the 
lymphatic  glands  of  the  neck  to  be  so  much  involved  in  addition  to  the 
parotids  as  to  modify  considerably  the  typical  appearance  of  the  subjects 
of  this  disease. 


196  ACUTE  FEBRILE  DISEASES. 

We  occasionally  meet  with  inflammation  of  the  parotid  glands  in  the- 
course  or  as  the  sequel  of  other  diseases,  such  as  enteric  fever  (though 
very  rarely  in  children),  scarlatina,  measles  and  small-pox.  I  have  also 
seen  it  several  times,  but  in  adults  only,  in  patients  with  gastric  ulcer  who> 
were  being  fed  exclusively  by  the  rectum.  In  such  cases  the  swelling  is 
generally  unilateral  throughout,  and  may  proceed  to  suppuration.  Any 
diagnostic  difficulty  hereby  presented  will  usually  be  dispelled  during  the 
progress  of  the  case.  The  swelling  in  true  mumps  is  almost  always  at 
last  bilateral,  although  the  involvement  of  the  second  side  may  occa- 
sionally be  long  delayed ;  suppuration  is  extremely  rare ;  and  there  is 
scarcely  ever  any  cutaneous  redness  or  much  tenderness  on  pressure  over 
the  enlarged  glands.  The  chief  complaints  made  in  mumps  are  more  or 
less  dull  aching  pain  in  some  cases,  and,  in  nearly  all,  difficulty  in  opening 
the  mouth  and  considerable  pain  in  attempting  to  masticate.  In  most 
cases  that  I  have  seen,  pain  on  movement  of  the  jaw  was  apparently  the 
first  symptom  of  the  disease.  Deafness  is  sometimes  complained  of,, 
and  there  is  occasionally  either  dryness  of  the  mouth  or,  for  a  while, 
increased  salivation.  The  symptoms  of  prodromal  feverishness  may  pre- 
cede the  local  complaint  for  a  few  days,  but  are  very  often  absent  or 
unnoticed,  and  the  temperature  at  the  height  of  the  attack  is  rarely  more 
than  102°.  The  swelling  usually  reaches  its  height  about  four  days  after 
its  first  appearance,  and  then  gradually  recedes  for  a  similar  or  somewhat 
longer  period.  Having  never  had  occasion  to  study  any  number  of  cases 
during  an  epidemic  I  can  say  nothing  personally  either  of  the  so-called 
"  metastasis  "  to  the  testes,  which  all  authorities  agree  to  be  very  rare,  at 
least  before  puberty,  or  of  that  to  the  ovaries  or  mammas,  which  is  perhaps 
problematical.  I  have  once  seen  pericarditis,  otherwise  unaccountable, 
following  immediately  on  an  attack  of  mumps,  but  no  stress  can  be  laid 
on  this  coincidence. 

The  period  of  incubation  seems  to  be  from  one  to  three  weeks.  One 
case  of  mine  pointed  almost  conclusively  to  an  infection  of  the  latter 
date.  The  event  of  mumps  is  almost  always  favourable,  with  no  sequelae. 
Although  the  disease  is  probably  highly  infectious  the  questions  of  isola- 
tion and  quarantine  may,  in  my  opinion,  be  left  to  the  discretion  of  those 
concerned. 

Nothing  is  usually  required  in  the  way  of  treatment  besides  confine- 
ment to  the  house  or  room,  or  to  the  bed  when  there  is  considerable 
fever,  and  hot  local  applications  when  there  is  much  discomfort. 
Ordinary  remedies  for  the  febrile  condition  may  be  given  should  relief 
of  symptoms  seem  to  require  them. 

This  disease  very  seldom  attacks  infants,  and  is  rare  in  early  child- 
hood. 


CHICKEN-POX,  MUMPS  AND  INFLUENZA.  197 


Influenza. 

Although  influenza  is  neither  mainly  nor  most  severely  incident  on 
childhood,  my  experience  of  the  recent  epidemics  of  189 1  and  1892 
leads  me  to  write  very  shortly  of  some  of  its  manifestations  in  young 
children,  which  are  on  the  whole  less  distinctive  and  thus  much  more 
•often  overlooked  than  is  the  case  with  adults.  It  is  not  within  my  scope 
to  discuss  or  detail  the  characters  of  this  disease.  I  shall,  therefore, 
state  that,  from  the  experience  I  have  had,  I  regard  it  as  a  specific  con- 
tagious fever,  mainly  of  epidemic  character,  with  acute  onset  and  varying 
duration ;  liahle  to  relapse ;  and  not  seldom  recurring  in  the  same  indi- 
vidual in  one  or  more  subsequent  epidemics.  The  actual  fever  lasts 
usually  for  not  more  than  three  or  four  days,  often  for  a  much  shorter, 
and  occasionally,  although  without  discoverable  complication,  for  a  con- 
siderably longer  period.  The  attack  begins  almost  always  with  either  a 
definite  rigor  or,  more  often,  a  feeling  of  chilliness,  as  expressed  hy  almost 
<dl  patients  old  enough  to  describe  their  sensations.  It  is  attended  by 
general  discomfort  and  usually  by  distinct  pain,  mostly  in  the  back  and 
legs,  with  as  a  rule  more  or  less  severe  headache,  great  prostration,  and 
drowsiness.  Some  cough,  generally  frequent,  hard  and  painful,  though 
sometimes  very  slight,  marks  most  cases  at  all  ages,  and  is  often  so 
paroxysmal  in  its  nature  as  to  be  quite  indistinguishable  from  a  typical 
attack  of  whooping-cough.  Of  this  I  have  seen  several  examples  in 
adults  as  well  as  children.  In  my  own  experience  of  the  recent  epi- 
demics coryzal  symptoms  were  decidedly  rare  both  in  children  and  in 
adults.  Diarrhoea  was  frequent ;  nausea  or  actual  vomiting  by  no  means 
uncommon  even  long  after  the  subsidence  of  the  fever ;  and  the  attack 
was  often  followed  by  giddiness,  neuralgia  in  various  parts,  and  many 
other  symptoms  of  nerve  disturbance  enduring  for  a  long  and  indefinite 
time,  with  much  prostration  and  often  with  obstinate  anorexia, 

In  a  certain  number  of  cases,  proportionately  very  great  in  children, 
there  were  inflammatory  attacks  of  the  respiratory  tract  over  and  above 
the  laryngotracheal,  tracheal,  or  large-bronchial  catarrh  which,  in  some 
degree,  may  be  regarded  as  part  of  the  clinical  picture  of  the  type-disease. 
Such  attacks  were  acute  general  bronchitis,  often  of  the  so-called  capillary 
form,  or  demonstrable  broncho-pneumonia.  Occasionally  also,  though  in 
my  experience  much  less  often  than  was  apparently  the  case  in  that 
of  others,  what  was  seemingly  ordinary  pneumonia  occurred,  strictly 
limited  to  one  side,  beginning  acutely,  and  ending,  after  a  typical  course 
of  signs  and  symptoms,  with  a  critical  fall  of  temperature  attended  by 
sweating.  Judging,  however,  from  the  numerous  cases  I  have  myself  seen 
at  all  ages,  including  some  which  were  fatal  and  were  examined  post- 


198  ACUTE  FEBRILE  DISEASES. 

mortem,  I  must  emphatically  state  that  the  lung-inflammation  proper  to^ 
influenza  is,  in  an  overwhelming  majority  of  instances,  unquestionably 
broncho-pneumonic.  In  children,  indeed,  a  severe  broncho-pneumonia, 
beginning  acutely  but  running  an  indefinite  course  with  signs  of  much 
bronchitis,  may  be  the  chief  and  perhaps  only  definite  indication  of 
influenza.  Such  cases  occurring  in  children  over  three  or  four  years 
old,  with  no  history  whatever  of  antecedent  illness  either  acute  or  chronic,, 
were  exceedingly  frequent  during  the  influenza  epidemics  of  1891  and 
1892,  and,  considering  that  acute  broncho-pneumonic  attacks  of  so-called 
simple  or  catarrhal  nature  are  almost  unknown  at  this  and  later  ages, 
there  seemed  to  be  no  doubt  of  their  truly  influenzal  origin.  An 
additional  reason  for  regarding  these  cases  as  specific,  even  in  the- 
frequent  absence  or  slight  prominence  of  other  symptoms  of  the  disease, 
was  the  concurrence  in  the  same  family  or  house  of  typical  instances  of 
adult  influenza.  "Without  this  latter  factor  the  diagnosis  of  influenza 
in  infants  is  often  very  difficult,  and  I  am  inclined  to  think  that  this 
was  the  chief  reason  for  the  prevalent  belief,  in  which  I  strongly  shared, 
during  the  epidemic  of  1889-90 — the  first  in  the  experience  of  most 
of  us — that  children  as  a  rule  escaped  the  disease.  In  the  following 
years,  however,  I  observed  an  unusual  prevalence  of  acute  bronchitis  and 
broncho-pneumonia  in  previously  healthy  infants  with  good  surroundings, 
which  disappeared  coincidently  with  the  subsidence  of  each  epidemic. 

It  must  also  be  remarked  that  in  several  cases  in  infants  and  quite 
young  children,  which  for  the  reasons  above  stated  I  regarded  as  in- 
fluenzal, drowsiness,  starting  during  sleep,  sudden  screaming  and  occasional 
squinting,  with  fever,  were  observed ;  and  that  the  diagnosis  of  menin- 
gitis was  frequently  suggested  and  even  sometimes  adhered  to  by  medical 
observers.  There  was,  however,  no  paralysis  nor  spasm,  other  than 
occasional  slight  convulsions  in  one  or  two  cases,  nor  any  other  evidence 
of  meningitis ;  and  the  patients  always  recovered. 

I  have  not  made  careful  observation  of  enough  cases  to  enable  me  to 
say  whether  or  not  there  are  other  distinctive  points  worthy  of  notice 
in  the  influenza  of  young  children.  Ear-ache  was  certainly  frequent 
even  in  otherwise  uncomplicated  instances.  Sometimes  tuberculosis, 
either  of  the  lungs  or  brain,  made  its  appearance  as  a  sequel  of  what 
was  apparently  an  influenzal  attack.  I  have,  however,  several  times  seen 
phthisis  in  adults  starting  with  the  lung-inflammation  of  influenza. 

Apart  from  the  occurrence  of  severe  broncho-pneumonia,  I  believe 
influenza  to  be  rarely  fatal  in  children.  Sometimes,  though  far  less  fre- 
quently than  in  adults,  there  is  weakness  and  protracted  convalescence. 

Concerning  medicinal  treatment  there  is  nothing  special  to  say.  I 
have  usually  given  quinine,  with  strychnia  or  nux  vomica;  and  often 
antipyrin  or  salicylate  of  soda,  with  apparently  good  effect,  when  there 


ENTERIC  FEVER.  I  99 

was  much  pain.  There  is,  according  to  my  experience,  no  reason  to 
believe  that  either  the  salicylate  or  salicin  itself  has  any  effect  on  the 
morbid  process ;  and  the  latter  drug  seems  to  be  here,  as  it  certainly  is 
in  acute  rheumatism,  a  much  less  certain  anodyne  than  the  former. 
For  the  rest,  confinement  to  bed  at  once  and  for  some  days  after  the 
fever  is  over ;  abundant  food  as  soon  as  the  appetite  returns,  and  plenty 
of  concentrated  liquid  nutrients  when  it  does  not ;  and  alcoholic  stimu- 
lants, in  small  doses  frequently  repeated,  when  there  is  much  prostra- 
tion, are  the  chief  points  to  be  observed.  If  convalescence  flags,  change 
of  scene  with  plenty  of  fresh  air  and  other  hygienic  remedies,  assisted  by 
a  course  of  arsenic  and  iron  with  or  without  cod-liver  oil,  is  strongly  to 
be  recommended. 


CHAPTEK    VII. 

ENTERIC    FEVER. 

This  disease  is  mainly  incident  on  childhood  and  youth  and  is  especially 
frequent  between  five  and  fifteen  years  of  age.  Under  two  years  of  age 
it  is  rare.  In  the  second  quinquennium  its  fatality  is  less  than  either 
before  or  afterwards,  and  after  the  eleventh  or  twelfth  year  differs  but 
little  from  its  average  at  all  ages.  From  my  own  experience  and  a  study 
of  the  records  of  the  fever  hospitals  I  am  convinced  that  the  danger  of 
enteric  fever  in  childhood  is  usually  much  under-rated ;  and  it  would 
seem  that  the  lesser  death-rate  under  twelve  years  of  age,  which  is  about 
four  to  five  per  cent,  below  the  average  at  all  ages,  is  mainly  due  to  the 
comparative  rarity  of  deep  ulceration  with  its  frequently  consequent 
perforation. 

Although  our  central  conception  of  enteric  fever  must  be  that  of  an 
infectious  disease  with  special  symptoms,  due,  in  all  probability,  to  the 
action  of  a  specific  bacillus,  and  marked  post-mortem  by  inflammation  or 
ulceration  of  Peyer's  patches  and  the  solitary  glands  of  the  ileum,  Ave 
nevertheless  sometimes  meet  with  cases,  clinically  indistinguishable  from 
the  type-form,  which  either  show  no  very  characteristic  lesion  after  death 
or  may  be  marked  by  ulceration  of  the  large  intestine  alone.  On  the 
other  hand,  the  well-known  ulcerative  lesion  and  even  perforation  may 
be  found  in  cases  which  have  run  a  short  course  with  no  specially  diag- 
nostic symptoms.  It  is,  according  to  my  experience,  only  in  adult  life 
hat  ulceration  exclusively  occupying  the  large  intestine  accompanies  a 
fever  which  has  all  the  clinical  marks  of  enteric ;  but  it  is  common  in 


200  ACUTE  FEBRILE  DISEASES. 

childhood  to  find  only  swelling  and  softening  of  Peyer's  patches  and  of 
the  solitary  glands,  without  ulceration,  and  this  not  only  in  cases  where 
early  death  may  have  anticipated  ulceration  but  also  in  those  of  pro- 
longed duration.  Swelling  and  even  softening  of  Peyer's  patches  is 
certainly  not  confined  to  enteric  fever  in  young  children ;  and,  when  we 
reflect  on  all  these  facts  and  on  some  clinically  anomalous  cases  of  fever 
which  we  occasionally  meet  with  at  all  ages,  unmarked  by  the  charac- 
teristic post-mortem  lesion,  we  must  either  entertain  doubts  that  enteric 
fever,  as  generally  diagnosed  during  life,  is  always  one  and  the  same 
affection,  or  question  the  claim  of  disease  of  Peyer's  patches  to  be  a 
strictly  integral  part  of  its  definition. 

The  contagiousness  of  enteric  fever  is  still  a  matter  of  debate  among 
clinicians.  Without  entering  here  into  a  detailed  support  of  my  own 
views,  which  are  largely  based  on  my  experience  at  a  children's  hospital 
as  well  as  among  adults,  I  would  state  my  agreement  with  the  opinion 
of  Collie  and  other  authorities  that  the  disease  is  frequently  conveyed 
directly  from  the  sick  to  those  in  attendance  upon  them,  and  that  young 
nurses  are  especially  apt  to  suffer.  I  regard  it  as  proved  that  the  active 
contagium  is  not  confined  to  the  decomposing  faeces,  but,  at  the  same 
time,  as  still  somewhat  doubtful  whether  it  is  carried  by  other  emana- 
tions than  the  intestinal  discharges.  It  is  of  course  almost,  if  not  quite, 
impossible  to  prove,  in  any  given  case  of  apparent  contagion,  that  some 
faecal  matter  has  not  been  conveyed  directly  to  the  mouth  after  handling 
the  patient ;  but  I  have  seen  a  sufficiently  large  number  of  examples  of 
infection  of  nurses  and  others  in  attendance  on  enteric  cases  when  there 
has  been  no  diarrhoea,  and  when  all  precautions  with  respect  to  cleanliness 
were  with  the  greatest  degree  of  probability  observed,  to  cause  me  to 
regard,  for  practical  purposes  at  least,  the  possibility  of  contagion  apart 
from  faecal  convection  as  by  no  means  disproved.  I  am  further  of  opinion, 
owing  to  some  important  experience  I  have  had,  that,  however  seldom 
enteric  fever  may  spread  to  other  patients  in  a  hospital  ward,  the  massing 
together  of  several  cases  may  reinforce  the  contagium  and  be  in  all 
probability  a  source  of  direct  infection  through  the  air.  Hence  I  would 
discourage  the  simultaneous  admission  of  more  than  a  very  few  cases 
even  to  a  large  general  ward,  and,  in  private  cases,  forbid  all  children  and 
young  people  access  to  the  patient's  room.  I  cannot  dwell  here  on  the 
other  recognised  sources  of  infection  from  drains,  drinking  water,  milk 
and  the  like ;  but  would  insist  on  unremitting  attention  to  personal 
cleanliness  on  the  part  of  the  attendants  on  the  sick,  and  on  the  dis- 
infection of  all  discharges  and  soiled  linen  according  to  well-known 
methods. 

Assuming  the  reader's  knowledge  of  the  typical  phenomena  and  course 
of  the  disease,  I  shall  confine  myself  here  to  the  notice  of  such  points  in 


ENTERIC  FEVER.  201 

symptomatology  as  seem  to  be  more  or  less  peculiar  to  its  examples  in 
childhood. 

The  duration  of  the  actual  fever  is  certainly  much  more  often  under 
three  weeks  than  in  adults,  and  is  sometimes  under  two.  If  there  be 
absence  of  diarrhoea,  rose-spots  and  splenic  enlargement,  as  well  as  of  the 
typical  temperature-curve,  some  diagnostic  doubt  may  continue  even 
after  recovery ;  but  this  difficulty  is  not  often  met  with  in  practice. 
There  are  but  few  cases  of  fever  which  run  a  course  of  even  ten  days 
or  a  fortnight  without  some  characteristic  signs,  and  it  is  but  seldom 
that  we  have  to  diagnose  enteric  fever  on  purely  negative  grounds. 
I  have  hitherto  failed  to  recognise,  as  some  authorities  do,  any  con- 
siderable class  of  cases  of  apparent  febricula  or  simple  continued  fever 
which,  from  the  lack  of  distinctive  symptoms  alone,  deserves  to  be  called 
enteric. 

In  spite  of  the  frequent  difficulty  of  ascertaining  the  date  of  onset  of 
the  disease,  I  am  fully  satisfied,  from  otherwise  typical  cases  where  this 
date  could  be  accurately  fixed,  that  at  least  in  early  childhood  the  whole 
course  of  the  fever  is  sometimes  considerably  under  a  fortnight. 

When  a  case  lasts  longer  than  four  weeks  there  is,  generally,  progressing 
ulceration  of  intestine  with  more  or  less  continuous  diarrhoea.  Such 
cases  are  grave,  but  I  have  seen  several  recover  perfectly  even  after 
two  or  three  months'  course  with  no  apyretic  interval. 

The  temperature  shows  greater  variation  from  the  typical  curve  than 
in  adults,  and  this  not  only  in  cases  of  short  duration.  In  scarcely  more 
than  half  of  my  cases  are  the  charts  so  significant  as  in  a  vast  majority 
of  adult  patients.  This  phenomenon  is  in  keeping  with  others  dependent 
on  the  readily  modifiable  action  of  the  nervous  system  in  early  life. 
Not  only  does  the  temperature-curve,  even  in  severe  cases,  often  touch 
the  normal  line  in  the  earlier  part  of  the  fever  day,  and  show  a  much 
greater  comparative  rise  in  the  later  part  than  in  adults,  but  also  the 
general  range  of  temperature  is  frequently  higher.  It  is  pre-eminently 
true  in  childhood  that  the  severity  of  the  disease  is  by  no  means 
always  proportionate  to  the  average  height  of  the  temperature,  and  the 
remembrance  of  this  fact  will  often  be  a  check  on  meddlesome  or  harmful 
treatment.  In  convalescence,  too,  the  temperature,  far  more  often  than 
in  adults,  rises  unexpectedly  for  a  short  time.  Such  a  rise  in  some 
cases  is  certainly  associated  Avith  constipation  and  disappears  with  its 
relief.  Constant  subnormality  during  early  convalescence  to  the  extent 
of  one,  two,  or  even  three  degrees,  and  also  irregularity  of  temperature 
are  observed  in  a  majority  of  cases,  especially  in  those  where  there  is 
rapid  recovery  after  great  wasting.  This  phenomenon  may  occur  in 
adults,  but  is  far  more  frequent  in  children. 

Sudden  onset  of  the  fever  is  very  often  seen  in  childhood.     Out  of  a 


202  ACUTE  FEBRILE  DISEASES. 

series  of  62  cases  under  14  years  old,  the  exact  day  of  onset  could  be 
fixed  in  24  by  definite  symptoms,  the  child  having  been  previously  to 
all  appearance  perfectly  well ;  and  in  many  more  the  beginning  of  malaise 
and  anorexia  was  very  nearly  dated.  In  adults  insidious  onset  is  far 
more  frequent,  although,  according  to  my  experience,  by  no  means  so 
prevalent  as  is  usually  taught.  Among  the  symptoms  referred  to,  head- 
ache almost  always  occurs,  shivering  or  rigors  usually,  and  vomiting  in 
most  cases.  Pain  in  the  belly,  sometimes  severe,  is  often  complained 
of,  especially  in  cases  where  diarrhoea  is  an  early  symptom ;  and  there  is 
frequently  much  aching  of  the  back  or  legs.  Occasionally  tonsillitis 
is  an  early  symptom. 

Diarrhoea,  in  the  sense  of  three  or  four  loose  motions  in  the  twenty-four 
hours,  occurs  at  some  period  in  most  cases.  It  is,  however,  still  more  rarely 
in  children  than  in  adults  that  very  large,  frequent  and  watery  motions 
are  noted  in  cases  which  recover ;  and  excessive  diarrhoea  at  any  age  may 
be  regarded  as  both  an  exceptional  and  grave  symptom.  Constipation 
after  the  first  week  is  observed  in  perhaps  about  one-fourth  of  all 
cases  in  children,  and  in  a  much  smaller  number  is  more  or  less  per- 
sistent throughout.  This  condition  is  somewhat  more  frequent  than 
in  adults,  owing  probably  to  the  less  severe  inflammation  and  rarer 
ulceration  of  the  intestinal  glands;  extent  of  intestinal  involvement 
being  roughly  proportionate  to  amount  of  diarrhoea.  Cases  with  per- 
sistent constipation  are,  however,  by  no  means  always  of  the  mildest, 
for  both  in  adults  and  children  they  may  be  marked  by  high  and  pro- 
tracted fever,  by  severe  pulmonary  and  other  complications,  or  even, 
as  I  have  more  than  once  seen,  by  deep  though  very  limited  intestinal 
ulceration  with  fatal  peritonitis  from  perforation.  I  would  state  here 
that  among  fatal  cases  in  childhood,  with  or  without  much  diarrhoea,  per- 
foration does  not  appear  to  be  proportionately  less  frequent  than  in  later 
life,  although  its  symptoms  may  be  more  obscure.  Certain  epidemics  of 
enteric  fever  appear  to  be  marked  by  frequent  instances  of  constipation, 
while  in  others  diarrhoea  occurs  in  a  large  majority  of  cases. 

Splenic  enlargement  can  usually  be  established  by  careful  palpation 
after  the  first  week ;  but  it  is  rarely  detectable  before  the  eruption  appears, 
and  is  therefore  of  no  great  diagnostic  value  except  in  cases  where  the 
eruption  is  very  late  or  altogether  absent.  It  may  persist  for  a  week 
or  more  after  convalescence  sets  in ;  or  may  soon  disappear,  as  far  as 
palpation  can  prove,  even  in  cases  which  subsequently  relapse.  Deter- 
mination of  the  spleen's  size  by  percussion  is,  I  think,  seldom  accurate 
enough  to  be  of  much  practical  use.  In  children  the  sign  of  splenic 
enlargement  is  even  of  less  value  than  in  adults,  for  their  spleens  are  apt 
to  become  palpably  enlarged  in  other  febrile  conditions.  Tenderness  in 
the  splenic  region  is  very  common,  and  more  characteristic  when  it  can 


ENTERIC  FEVER.  203 

be  satisfactorily  isolated  from  the  general  abdominal  tenderness  so  often 
observed. 

Rose-spots  are  but  seldom  absent.  They  were  noted  in  48  out  of 
62  cases  after  admission  to  hospital  at  varying  periods  of  the  disease. 
Careful  observation  after  the  fifth  or  sixth  day  will  establish  their  exist- 
ence in  an  immense  majority  of  cases.  Often,  however,  they  are  infre- 
quent and  may  occur  in  single  or  only  two  successive  crops ;  they  may 
last  but  one  or  two  days,  and  are  sometimes  seen  only  on  the  back. 
Very  occasionally  there  is  a  scarlatiniform  rash  on  the  body  in  the  early 
time  of  the  fever,  especially  in  cases  which  begin  suddenly.  This  rash 
may  endure  for  several  days,  spreading  from  the  face  downwards.  At 
first  it  may  be  difficult  in  such  cases  to  exclude  the  diagnosis  of  scarlatina, 
but  the  throat  is  not  characteristically  affected  nor  is  there  any  subse- 
quent desquamation. 

Bronchitis,  with  or  without  much  cough  or  dyspnoea,  and  often  so 
slight  as  to  be  detectable  only  on  careful  examination  after  deep  inspira- 
tion, is  the  rule  in  enteric  fever  with,  I  think,  fewer  exceptions  than  in 
adults,  and  may  be  regarded  more  as  one  of  the  expressions  than  as  a 
complication  of  the  disease.  Even  when  there  is  no  cough  slight  bron- 
chitic  signs  are  exceedingly  often  observable.  Sometimes  the  gravity  of 
the  illness  is  mainly  due  to  this  bronchial  involvement,  which  may  mask 
other  symptoms  and  cause  difficulty  in  diagnosis  almost  from  the  begin- 
ning. Occasionally  in  protracted  cases  it  seems  to  be  the  cause  of  death. 
Evidence  of  bronchitis  can  very  often  be  established  by  examination  of 
the  front  of  the  chest  alone.  Broncho-pneumonia  is  not  very  rare, 
but  is  less  often  detected  by  signs  during  life  than  demonstrated  post- 
mortem. 

The  heart  almost  always  suffers  in  enteric  fever  to  a  degree  discover- 
able by  examination.  In  numerous  cases  with  perfect  recovery  I  have 
observed  complete  absence  of  the  first  sound  for  many  days,  and  in 
still  more  the  first  and  second  sounds  were  for  long  indistinguishable 
from  one  another.  We  often  hear  a  rapid  succession  of  short  sounds, 
the  normal  pauses  being  abolished.  The  impidse  is  proportionately 
diminished,  or  impalpable.  In  protracted  and  severe  cases  bilateral 
ventricular  dilatation  may  be  made  out ;  and  I  have  sometimes  heard 
a  soft  but  well-marked  systolic  murmur  at  the  apex,  which  has  after- 
wards disappeared  with  the  return  of  the  heart's  dulness  to  its  normal 
dimensions.  This  cardiac  feebleness  and  dilatation  are  of  great  clinical 
importance,  and  are  evidenced,  symptomatically,  by  the  extreme  rapidity  of 
pulse  and  occasional  syncope  which  follow  on  movement  or  on  suddenly 
sitting  up,  and,  anatomically,  by  the  softness,  fiabbiness  and  thinning  of 
the  heart's  walls  Avhich  have  been  frequently  found  post-mortem.  Actual 
myocarditis  may  occur,  of  which  I  have  seen  one  well-marked  instance. 


204  ACUTE  FEBRILE  DISEASES. 

Not  the  radial  pulse  alone,  therefore,  but  also  the  heart  should  be 
constantly  and  carefully  examined  before  allowing  patients  to  rise 
from  bed  or  sit  up.  The  morbid  condition  of  the  heart  may  long 
outlast  the  fever,  and  is  a  strong  indication  for  the  greatest  caution 
in  convalescence. 

In  many  of  the  complications  of  enteric  fever  there  is  nothing  special 
to  childhood.  Laryngeal  ulceration ;  tonsillitis  with  exudation,  not  easily 
distinguishable  from  diphtheria  and  causing  much  dysphagia  which 
should  always  suggest  examination  of  the  fauces ;  epistaxis ;  otitis ;  glan- 
dular and  cellular  abscesses  •  bullous  eruptions ;  parotiditis,  and  venous 
thrombosis  are  certainly  rare,  and  probably,  with  the  exception  of  ton- 
sillitis, rarer  in  children  than  in  adults.  In  one  case,  aged  7^  years, 
which  ultimately  made  a  good  recovery,  peritonitis  set  in  during  the 
fifth  week,  and  after  a  while  there  was  swelling  and  purulent  discharge 
from  the  umbilicus.  The  swelling  was  incised  and  drained.  There 
were  also  bed-sores,  multiple  abscesses,  pericarditis  and  pleural  effusion. 
Occasionally  we  meet  with  cases  of  destructive  arthritis,  peri- ostitis,  and 
necrosis  of  jaw. 

Special  nervous  symptoms  are  not  common,  although  deafness,  without 
otitis,  and  some  amount  of  delirium,  are  very  frequent.  I  have  known 
one  case  of  definite  meningitis  following  on  purulent  otitis,  one  case  of 
typical  hemiplegia,  and  a  few  instances  of  indefinite  paraplegic  weak- 
ness with  ataxia.  In  some  cases  which  perfectly  recover  there  is  retrac- 
tion of  the  head,  with  other  apparently  cerebral  symptoms  such  as  the 
"  tache,"  photophobia,  and  great  drowsiness.  Marked  mental  changes, 
both  in  the  direction  of  mania  and  imbecility,  are  rare  in  childhood, 
though  met  with  by  most  observers  from  time  to  time  in  adults.  I 
have,  however,  seen  several  cases  where  children,  after  a  long  and  severe 
attack,  became  forgetful  and  silly  for  a  considerable  time  and  were 
unable  or  unwilling  to  speak. 

Relapses  in  the  sense  of  fresh  febrile  attacks  with  distinctive  symptoms, 
occurring  several  days  after  the  establishment  of  apparent  convalescence, 
are  from  all  accounts  not  so  frequent  in  children  as  in  adults.  I 
have,  however,  seen  many  cases.  More  common  is  the  recrudescence, 
often  repeated,  of  symptoms,  with  or  without  apyretic  intervals  of  a  day 
or  two.  Owing  to  these  relapses  and  recrudescences  the  whole  course 
of  the  disease  may  be  prolonged  for  months,  and  yet  perfect  though 
tedious  recovery  ensue.  That  true  relapses  are  mostly  milder  than  the 
primary  attack  is  perhaps  a  statistical  truth,  but,  in  my  experience,  of 
no  practical  moment  in  prognosis.  I  have  seen  several  instances  of 
far  greater  severity  during  relapse.  True  relapses  are  but  seldom  trace- 
able to  dietetic  errors,  such  possible  exciting  causes  being  positively 
excluded  in  most  cases ;  but  return  of  diarrhoea,  with  heightened  fever 


ENTERIC  FEVER.  205 

and  other  symptoms  \yliich  constitute  recrudescence,  is  sometimes  in  all 
probability  referable  to  careless  feeding. 

Diagnosis. — Among  the  diseases  which  may  be  confused  with  enteric 
fever  either  early  or  late  in  the  course  of  the  affection  I  would  mention 
pneumonia,  meningitis,  bronchitis,  phthisis,  and  acute  tuberculosis. 

Pneumonia  is  sometimes  evidenced  by  only  very  late  physical  signs 
or  by  none  at  all ;  and  may   involve  but   slight   respiratory  trouble. 
Beginning  with  similar  symptoms  to  those  of  some  cases  of  enteric  fever, 
this  disease  may  then  be  very  difficult  of  diagnosis  until  a  definite  pneu- 
monic crisis  may  remove  doubt.     The  diagnosis  of  enteric  fever  is  at  the 
best,  during  the  first  week,  a  process  of  exclusion.     Meningitis,  especially 
tubercular,  may  closely  simulate  enteric  fever,  from  which  it  is  by  no 
means  always  to  be  separated  by  the  infrequent  pulse  which  is  insisted 
on  by  many.      The   cleaner  tongue,  however,  the  normal,  doughy  or 
retracted  abdomen  and  the  intense  dislike  of  disturbance  will  greatly  aid 
us  in  excluding  the  probability  of  enteric  fever.     Bronchitis  has  often 
been  diagnosed  as  the  primary  affection  in  the  second  week  or  later  in 
this  disease,  when  distinctive  symptoms  have  disappeared  or  are  masked. 
Eemembrance  of  the  rarity  of  simple  and  extensive  bronchitis  after  in- 
fancy has  more  than  once  led  me  to  suspect  and,  subsequently,  correctly 
diagnose  enteric  fever  from  the  mere  presence  of  severe  bronchitis  with 
fever  of  some  duration.    Phthisis  is  sometimes  diagnosed  in  cases  of  enteric 
fever  coming  late  under  observation.    Much  wasting,  with  bronchitis  and 
perhaps  doubtful  pulmonary  signs,  and  other  phthisical  symptoms  are  often 
salient  phenomena  in  late  enteric  fever;  and  in  some  cases  the  correct  diag- 
nosis can  only  be  arrived  at  by  a  careful  retrospect  on  the  recovery  of  the 
patient.     Cases  of  extreme  wasting  due  to  enteric  fever  which  has  never 
been-  recognised  have  several  times  come  under  my  notice  and  caused 
great  diagnostic  difficulty.    Acute  general  tuberculosis  may  be  mistaken  for 
enteric  fever  after  even  careful  observation ;  but  the  rarity  of  this  form 
of  tuberculosis,  especially  after  infancy,  is  much  greater  than  the  fre- 
quent mention  of  this  possible  diagnostic  difficulty  would  lead  us  to 
expect.     With  the  exception  of  some  temporary  hesitation  over  a  few 
cases  of  tubercular  peritonitis  with  some  diarrhoea,  I  have  but  rarely 
met  with  this  source  of  confusion  in  practice  after  a  careful  study  of 
any  case  in  question. 

There  are  several  other  affections,  among  which  is  influenza,  that  may 
be  mistaken  for  enteric  fever  in  the  first  week  or  even  later.  I  shall, 
however,  say  no  more  on  this  head  than  that  enteric  fever  may  begin 
in  almost  any  way,  and  that,  without  the  most  careful  observation  and 
thought,  it  should  never  be  positively  excluded  from  the  diagnosis  of 
any  case  of  illness  where  it  may  be  suspected  with  the  faintest  show 
of  reason.     We  must  always  provisionally  treat  a  fever  as  enteric  until 


206  ACUTE  FEBRILE  DISEASES. 

the  lapse  of  time  or  the  appearance  of  other  symptoms  remove  our 
suspicion. 

Treatment. — In  many  instances  of  enteric  fever  in  children  perfect 
rest  in  bed  from  the  earliest  possible  time,  and  assiduous  feeding  with 
milk  and  meat-juices,  in  proportions  varying  according  to   individual 
requirements  and  indications,  are  all  that  is  necessary  or  advisable  for 
the  successful  conduct  of  the  case.     Anorexia  and  refusal  of  food  is 
exceedingly  common.     While  adults  will  usually,  except  in  the  severer 
cases,  take  nourishment  fairly  well  throughout,  it  is  very  rare,  except 
in  the  mildest  cases,  to  meet  with  no  difficulty  in  this  respect  with 
children.     It  is  often  indeed  necessary,  even  in  the  absence  of  digestive 
disturbance  or  pharyngeal  difficulty,  to  feed  the  patient  by  the  nasal 
tube.      When   there   is   constipation,  which   is   often  associated   with 
tumidity  and  tenderness  of  the  abdomen,  the  amount  of  milk  must  be 
reduced,  and  more  beef-tea  or  other  meat-juice  substituted ;  or  a  raw 
egg  beaten  up  with  a  little  brandy  may  be  given  once  or  twice  a  day. 
With  persistent  diarrhoea  the  diet  should  be  mostly  or  exclusively  milk 
and  barley-water.     The  amount  of  food  must  be  regulated  by  the  age 
and,  as  far  as  possible,  by  the  individual   digestive    capacity  of   the 
patient.     But  we  are  often  in  the  dark  on  this  latter  point,  and  I  am 
sure,  from  some  cases  I  have  seen,  that  the  gravity  of  the  illness  is  often 
increased  by  an  excess  of  food,  especially  milk,  which  is  apparently 
well  digested.     In  such  cases  there  is  usually  constipation  which,  even 
when  attended  by  abdominal  discomfort,  is  often  neglected  on  principle. 
Such  a  condition,  however,  sometimes  calls  for  the  greatest  clinical  acumen 
in  deciding  upon  measures  of  relief.     In  my  opinion  constipation  should 
always  be  treated  by  small  and  simple  enemas  when  it  is  accompanied 
by  distension  or  discomfort,  by  the  escape  of  flatus,  or  by  the  presence 
of  palpable  scybala ;  while  mere  absence  of  bowel  action  without  these 
accompaniments  may  be  left  alone  even  for  many  days.     In  deciding  to 
act  on  the  bowels,  however,  while  the  fever  lasts,  the  greatest  caution 
should  be  observed ;  for  deep  ulceration  and  even  fatal  perforation  may 
occur  with  persistent  constipation.     Marked  nervous  symptoms  with 
tremor  should  give  us  pause  before  interfering  with  constipation.     After 
convalescence  is  established  the  constipation,  which  is  so  common,  fre- 
quently causes  discomfort  and  slight  rises  of  temperature,  and  should 
always  be  relieved,   though  cautiously,  by  enemas  or,  occasionally,  by 
mild  aperients.     In  this  context  I  cite  a  case  of  illness  where  constipa- 
tion, caused  by  an  excessive  diet  of  milk  and  by  abundance  of  astringent 
medicines  given  on  the  theory  of  the  disease  being  enteric  fever,  seemed 
to  induce,  or  at  least  encourage,  by  pressure  the  occurrence  of  very  scanty 
urine  highly  charged  with  blood  and  albumen  in  excess,  and  a  highly  dan- 
gerous degree  of  the  so-called  "  typhoid  "  condition.     The  patient  whom 


ENTERIC  FEVER.  207 

I  first  saw  on  the  eleventh  day  of  this  illness,  which  ultimately  was  proved 
to  he  scarlatina,  had  been  fed  throughout  on  six  pints  of  milk  and  two 
pints  of  beef-tea  daily.  The  abdomen  was  enormously  distended  with 
solid  matter.  Very  large  evacuations  produced  by  repeated  enemata 
were  followed  by  a  complete  subsidence  of  all  symptoms  and  disappear- 
ance of  all  blood  and  albumen,  with  a  copious  flow  of  urine,  within  thirty- 
six  hours  ;  rapid  recovery  ensuing  on  a  scanty  diet  with  scarcely  any  milk. 
Abdominal  pain  and  tenderness,  with  or  without  constipation,  and  parti- 
cularly when  accompanied  by  tremors,  restlessness  and  delirium,  should 
always  be  treated  by  opium  in  sufficient  doses  to  produce  drowsiness ; 
and,  if  there  be  more  than  three  or,  at  the  most,  four  copious  motions 
in  the  twenty-four  hours,  I  always  give  opium,  beginning  with  small 
doses.  With  prolonged  diarrhoea,  which  so  often  means  ulceration  of 
considerable  extent,  opium  should  be  given  persistently  and  freely  for 
its  healing  action.  I  have  frequently  seen  many  grave  symptoms  quickly 
recede,  and  both  appetite  and  vigour  increase,  after  the  bold  administration 
of  this  drug.  Bismuth  and  other  astringent  remedies  are  also  useful  in 
diarrhoea,  but  in  severe  cases  time  should  never  be  wasted  in  the  trial  of 
these  drugs  alone.  The  contra-indications  to  opium  are  as  a  rule,  though 
not  without  exception,  extreme  nerve-prostration  and  excessive  repug- 
nance to  food,  and,  always,  marked  respiratory  trouble. 

Frequent,  feeble  and,  especially,  dicrotic  pulse,  or  marked  weakening 
and,  still  more,  absence  of  the  first  heart-sound,  necessitate  alcohol.  So 
also  does  tremor  with  abdominal  discomfort.  It  is  always  well  to  omit 
the  alcohol  for  a  while  after  a  few  days,  for  if  we  persist  with  it  after 
the  desired  effect  is  produced  we  run  the  risk  of  paralysing  the  nerve 
centres  and  preventing  the  tendency  to  natural  recovery.  I  have  some- 
times seen,  on  omission  of  this  drug,  a  sudden  amelioration  of  symptoms 
which  were  doubtless  due  to  the  obscuration  by  alcoholic  narcosis  of  the 
natural  improvement  that  had  all  the  time  been  taking  place.  In  con- 
valescence alcohol  is  generally  advisable,  and  sometimes  necessary  when 
the  heart  has  suffered  much. 

Antipyretics  are  in  my  opinion  scarcely  ever  needed  in  childhood, 
and  but  rarely  at  any  age.  After  many  trials  of  both  quinine  and 
cool  baths  I  have  almost  abandoned  both,  and  from  some  experience 
of  antipyrin  am  of  opinion  that  it  is  generally  useless  and  sometimes 
harmful.  I  have  seen  some  cases  rapidly  improve  on  its  discontinu- 
ance, although  the  temperature  immediately  rose  after  its  artificial 
fall.  It  is,  however,  perhaps  permissible  and,  possibly,  useful  in  some 
degree  in  cases  where,  without  any  other  untoward  symptoms,  the  tem- 
perature remains  persistently  very  high.  Full  doses  should  never  be 
given,  on  account  of  the  frequently  depressing  effect  on  the  heart,  and, 
when  the  pulse  is  dicrotic  or  the  first  cardiac  sound  is  markedly  feeble, 


208  ACUTE  FEBRILE  DISEASES. 

this  drug  should  he  entirely  withheld.  Frequent  tepid  or  even  cold 
sponging  is,  however,  often  very  useful  in  treatment,  soothing  the  patient, 
inducing  sleep,  and  lessening  delirium.  In  my  opinion  it  is  scarcely 
ever  imperative  at  any  age  to  treat  the  temperature  per  se.  In  some 
severe  cases,  nevertheless,  with  persistently  high  temperature,  or  when 
hyperpyrexia  occurs,  I  give  quinine  in  large  doses  in  preference  to  cold 
haths  or  to  antipyrin.  The  temperature  can  thus  he  reduced  in  many 
cases ;  but  the  utility  of  this  procedure  is  open  to  much  doubt. 

Solid  food  should  not,  as  a  rule,  be  allowed  at  all  until  ten  or  twelve 
days  after  the  subsidence  of  the  fever.  Unformed  or  even  liquid  stools 
sometimes  follow  on  the  resumption  of  ordinary  diet,  owing  to  the  unac- 
customed stimulation  of  the  bowels.  We  should  always  satisfy  ourselves 
of  the  nature  of  such  stools  by  personal  inspection,  before  venturing  to 
continue  or  deciding  to  alter  the  diet.  For  solid  food  I  usually  begin 
with  bread  and  butter  or  fish,  and  occasionally  with  a  very  little  pounded 
meat.  Only  small  quantities  of  solid  diet  should  be  allowed  for  the  first 
week ;  subsequently,  if  all  goes  well,  but  little  restriction  need  be  placed 
on  the  satisfaction  of  the  appetite. 

Patients  should  never  be  permitted  to  exert  themselves  until  examina- 
tion shows  considerable  improvement  of  the  power  of  the  heart.  The 
longer  the  rest,  the  more  rapid,  as  a  rule,  is  the  convalescence.  Arsenic, 
iron,  and  the  best  hygienic  conditions  may  all  aid  in  establishing  perfect 
recovery. 

The  treatment  of  enteric  fever  can  be  written  about  in  but  very  general 
and  inadequate  terms.  Each  individual  case  demands  constant  attention 
and  often  varying  treatment,  and  no  bad  case  can  be  treated  in  the  best 
way  by  any  rules  whatever.  The  doctor's  acumen  and  the  nurse's  skill 
are  of  primary  importance  and  are  frequently  taxed  to  the  utmost. 

Concerning  the  theoretically  rational  attempt  to  treat  enteric  fever 
according  to  its  causal  indications  by  endeavouring  to  produce  intestinal 
asepsis  and  thereby  check  the  production  of  the  pathogenic  material,  I 
can  speak  but  little,  as  yet,  from  my  own  experience,  and  have  thus  left  it 
to  the  last.  Judging,  however,  from  the  possible  or  even  probable  good 
effects  of  the  internal  administration  of  "naphthalene"  or  "naphthol" 
in  the  septic  diarrhoeas  of  infants,  and  from  some  reports  of  cases  of 
enteric  fever  thus  treated,  I  am  inclined  to  think  that  an  extensive  use 
of  the  drug  from  the  commencement  of  symptoms  in  this  disease  is  well 
worthy  of  trial.  From  one  to  ten  grains  of  naphthalene,  in  divided  doses 
according  to  age,  may  probably  be  given  daily,  without  any  drawback 
other  than  the  unpleasant  taste  of  the  drug,  which,  however,  is  not  of 
much  moment,  considering  the  dulled  sensibilities  of  most  enteric  patients. 
The  very  slight  solubility  of  this  medicine  seems  to  favour  antiseptic 
operation  at  all  parts  of  the  intestinal  canal. 


RHEUMATISM  AND  ARTHRITIS  DEFORMANS.  20Q 


CHAPTER  VIII. 
RHEUMATISM    AND    ARTHRITIS    DEFORMANS. 

By  the  term  rheumatism,  which  I  use  synonymously  with  rheumatic  fever 
and  as  inclusive  of  both  acute  and  subacute  rheumatism,  ignoring  what- 
ever distinction  may  be  implied  in  these  latter  words  as  practically  useless, 
especially  in  the  case  of  children,  I  denote  the  well-known  general  affec- 
tion with  more  or  less  pyrexia,  which  is  marked  in  almost  all  instances, 
at  least  after  very  early  childhood,  by  some  arthritis  and  sweating ;  by 
inflammation  of  the  heart  and  pericardium,  at  least  before  puberty,  in  a 
considerable  majority ;  and,  very  frequently,  by  various  other  affections, 
especially  of  fibrous  and  serous  structures.  To  this  disease  only,  including 
certain  recurrent  or  chronic  symptoms  in  some  of  its  subjects,  I  apply 
the  term  "  rheumatism,"  which,  however  slight  and  obscure  some  expres- 
sions of  the  disease  it  denotes  may  be,  is  nevertheless  to  be  employed 
with  no  vague  meaning. 

Without  discussing  the  still  open  question  of  the  ultimate  pathology 
of  rheumatism  or  reviewing  the  numerous  hypotheses  of  its  origin, 
whether  exploded  or  extant,  I  must  here  merely  state  that  my  own 
experience  and  study  of  this  disease  at  all  ages  inclines  me  to  regard  it 
as  in  all  probability  essentially  due  to  a  faulty  condition  of  the  nervous 
system,  for  the  most  part  inherited,  which  expresses  itself  in  various 
inflammatory  and  other  modes  in  ready  reaction  to  diverse  impressions 
upon  the  nervous  periphery,  among  which  "  chill "  is  probably  to  be  re- 
garded as  the  chief.  At  present,  indeed,  neither  chemistry,  bacteriology, 
nor  morbid  anatomy  has  supplied  us  with  any  approach  to  an  ultimate 
explanation  of  the  source  and  phenomena  of  what  most  agree  in  recog- 
nising as  rheumatism  ;  and  it  must  be  admitted  that  its  clinical  facts  and 
conditions  seem  highly  unfavourable,  if  not  contradictory,  to  any  hypo- 
thesis of  germ-origin.  A  certain  small  number  of  cases  in  all  appearance, 
if  not  actually,  rheumatic,  and  often  marked  by  endo-  or  peri-carditis  and 
some  sweating,  are  well  known  to  follow,  sometimes  immediately,  on 
scarlatina,  apart  from  those  less  shifting  joint-swellings  without  cardiac 
involvement  which  are  alluded  to  under  the  heading  of  the  last-named 
disease.  It  may  scarcely  be  denied  that  scarlatina  is  the  exciting  cause 
of  these  attacks,  which  are  probably  truly  rheumatic. 

Symptomatology. — Although  the  heart-affection  of  rheumatism  is 
much  more  common  in  childhood  than  when  the  disease  is  first  developed 
at  a  later  age,  occurring  indeed  with  a  frequency  almost,  though  not 

0 


2  I  O  ACUTE  FEBRILE  DISEASES. 

quite,  inversely  proportionate  to  the  years  of  its  subjects,  so  that  those 
who  may  he  first  attacked  in  their  maturity  most  often  escape  heart- 
disease  altogether,  yet  without  doubt  the  younger  the  patient  the  less 
severe  and  enduring,  though  not,  in  my  opinion,  much  the  less  frequent 
or  at  all  the  less  recurrent,  are  the  arthritis  and  the  pyrexia.  Tonsillitis 
again,  and  both  dry  and  liquid  pleurisy,  which  are  frequent  in  rheumatic 
subjects  of  all  ages,  are  perhaps  seen  oftener  in  early  life ;  as  also  may 
be  certain  skin  affections,  such  as  erythema  nodosum,  urticaria,  and 
other  rashes,  sometimes  simulating  scarlatina,  and  occupying  chiefly  the 
arms  and  legs.  These  phenomena  and,  still  more  prominently,  endocar- 
ditis and  pericarditis  may,  indeed,  occur  from  time  to  time  as  the  only 
manifestations  of  rheumatism  afterwards  evidenced  by  an  attack  of 
arthritis.  Many  writers  include  chorea  as  often  or  indeed  almost  always 
an  indication  by  itself  of  the  rheumatic  tendency,  but  of  this  relationship 
I  treat  elsewhere.  The  fibrous  nodules,  of  subcutaneous  site,  hereafter 
to  be  shortly  described,  are  almost  wholly  confined  to  the  rheumatism  of 
childhood,  occurring  especially  or  exclusively  in  association  with  heart- 
disease. 

Typical  acute  rheumatism,  with  profuse  sour-smelling  sweat  and  severe 
arthritis,  with  much  swelling  and  redness,  shifting  from  joint  to  joint,  is 
undoubtedly  rare  in  little  children,  and  but  seldom  persists  in  childhood, 
although  untreated  by  salicin  or  the  salicylates,  for  that  period  of  two  or 
three  weeks  or  more  so  common  in  adult  cases  even  when  masked  or 
modified  by  medicines.  I  have,  however,  seen  one  instance  of  this  kind, 
strongly  characteristic  in  all  particulars,  in  a  child  of  2  \  years  with 
definite  rheumatic  heredity,  as  well  as  several  other  less  severe  but  still 
very  typical  cases  under  five  years  old.  Out  of  a  series,  moreover,  of 
70  cases  in  the  wards  at  Shadwell  Hospital  between  the  ages  of 
four  and  fourteen,  all  with  more  or  less  arthritis,  I  find  44  noted  as 
having  much  sweating,  many  of  them  with  the  familiar  sour  smell;  18 
with  slight  sweating ;  and  8  only  with  no  sweating  at  all  while  under 
observation.  In  the  parents'  history  of  some  of  these  latter  cases  there 
is  an  account  of  much  sweating  at  the  onset,  with  remarks  on  a  peculiarity 
of  smell.  I  mention  these  facts  because  there  seems  to  be  too  great  a 
tendency  on  the  part  of  some  writers,  who  rightly  urge  the  oft-times 
slight  and  elusive  characters  of  articular  rheumatism  in  childhood,  to 
underrate  largely  the  frequency  of  these  well-marked  cases,  and  to  multiply 
and  emphasise  unduly  the  distinction  between  the  symptoms  as  incident 
on  childhood  and  on  later  age.  As  a  result,  too,  of  these  views  rheu- 
matism in  childhood  becomes  so  wide  in  extent  as  to  be  almost  indefinite 
in  content ;  and  single  phenomena,  of  probably  or  certainly  multiform 
causation,  such  as  chorea,  tonsillitis,  erythema  and  others,  are  liable  to 
be  erroneously  attributed  to  a  necessarily  rheumatic  origin. 


RHEUMATISM  AND  ARTHRITIS  DEFORMANS.  2  I  I 

In  commenting  on  some  of  the  qualities  of  rheumatism  in  childhood 
I  shall  quote  largely  from  the  ahove-mentioned  70  cases,  registered  as 
"  acute  rheumatism,"  which  I  have  taken  consecutively  from  my  ward- 
books;  but  would  repeat  that  I  am  in  full  accord  with  those  who  urge  the 
frequency  of  less  well-marked  instances,  especially  in  young  children. 
This  is  amply  attested  by  many  further  cases  of  my  own  registered  as 
"  heart-disease,"  with  a  history  of  slight  and  evanescent  joint-pains 
without  observed  redness  or  swelling ;  and  by  some  others  which,  by 
reason  of  concomitant  symptoms  or  of  a  rheumatic  family  history  or  both, 
were  almost  certainly  instances  of  rheumatic  heart-disease  although 
lacking  evidence  of  any  arthritis.  There  are,  indeed,  comparatively 
few  cases  of  pericarditis,  and  still  fewer  of  endocarditis,  which  are  not 
either  certainly  or  with  the  greatest  probability  of  rheumatic  origin. 
Over  and  above  the  said  70  cases  of  rheumatism  I  have  noted  the 
positive  or  extremely  probable  occurrence  of  this  disease  in  77  out  of  98 
cases  of  endocarditis  in  my  wards,  as  well  as  in  17  out  of  26  registered 
as  "pericarditis."  I  would  add  here,  as  bearing  on  the  statement  that 
rheumatic  heart-affections  alone  are  frequent  in  children  without  any 
articular  symptoms  at  all,  that  in  several  cases  of  apparently  idiopathic 
pericarditis  and  endocarditis,  seen  outside  hospital  and  closely  observed 
by  the  mothers,  there  was  a  clear  report,  on  inquiry,  of  antecedent  joint- 
pains  which  would  have  certainly  escaped  the  parents'  notice  in  the  case 
of  most  hospital  patients. 

As  regards  incidence  on  sex  and  age  the  70  cases  may  be  briefly  tabu- 
lated as  follows,  the  ages  being  given  in  all  cases  at  the  date  of  the  first 
attacks.  It  will  be  seen  that  the  greater  liability  of  girls  does  not  begin 
until  after  the  age  of  10  years. 

Boys.  Girls. 

Under  5  years  old 1  (set.  4)     ... 

Between  5  and  10 17  17 

,,      10  and  14 13  22 

3i  39 

All  but  9  out  of  these  cases,  ranging  between  6  and  14  years  of  age, 
were  the  subjects,  while  under  observation,  of  either  old  heart-disease,  of 
active  peri-  or  endo-carditis  or  of  apical  systolic  murmurs.  In  9  of  these, 
including  4  with  both  mitral-valve  murmurs  (single  or  double)  and  signs 
of  pericarditis,  and  5  with  single  or  double  murmurs  only,  all  signs  and 
symptoms  of  cardiac  affection  disappeared  before  discharge. 

There  were  signs  of  pericarditis  in  19,  all  with  valve  murmurs  as  well ; 
and  the  rest  had  murmurs  mostly  mitral,  many  having  signs  of  heart- 
enlargement,  but  12  being  marked  by  no  enlargement  or  other  sign  or 
symptom  of  cardiac  disorder  than  a  soft  systolic  murmur  at  the  apex. 
It  would  thus  seem  likely  that  actual  rheumatic  heart-affection  may  not 


2  I  2  ACUTE  FEBRILE  DISEASES. 

seldom  disappear  in  childhood,  leaving  no  morbid  result ;  and  it  is  certain 
that  many  well-marked  systolic  murmurs  at  the  apex  pass  away,  whether 
due  to  valvulitis  or  to  temporary  regurgitation  through  the  mitral  orifice 
by  reason  of  ventricular  dilatation. 

Such  disappearance  of  blowing  murmurs  at  the  apex  is  familiar  to  us 
in  the  case  of  adults  as  well ;  but  it  is  especially  in  childhood  that  we 
must  hesitate,  and  sometimes  for  long,  before  inferring  heart-disease 
from  the  presence  of  an  apical  bruit  alone.  So-called  hseniic  murmurs 
at  the  base  and  over  the  ventricles  are  met  with  fairly  often  in  rheumatic 
children,  especially  when  the  anaemia  is  clinically  well-marked ;  but  I 
think  they  are  more  common  in  adult  cases.  Further  consideration 
of  the  symptoms  and  treatment  of  heart-disease  finds  place  under  its 
proper  heading. 

The  painful  onset  of  rheumatic  attacks  is  sometimes  accompanied  by 
rigors,  occasionally  by  vomiting,  and  not  very  rarely,  especially  when 
there  is  cardiac  involvement,  by  marked  prsecordial  or  epigastric  pain. 
Tonsillitis,  too,  is  often  an  early  symptom.  Many  cases,  however,  begin 
with  very  slight  joint-pain  which  afterwards  increases,  and  in  others 
there  may  be  at  first  only  slight  fever  and  sweating. 

The  arthritis,  which  we  have  already  seen  to  be  often  slight  and  some- 
times overlooked  or  possibly  non-existent,  is  certainly  of  much  shorter 
duration  in  children  under  1 2  than  later  on,  and  the  swelling  and  red- 
ness are  usually  much  less  in  proportion  to  the  pain.  I  have  often 
observed  acute  joint-pain  with  tenderness,  equal  to  that  of  severe  adult 
cases,  when  there  has  been  neither  redness  nor  tangible  swelling.  In 
very  many  cases  the  arthritis  is  confined  to  the  lower  extremities ;  in 
several  to  the  knees  alone. 

The  temperature  is  usually  of  an  actually  lower  range  than  in  adult 
rheumatism,  and  hyperpyrexia  is  very  rare.  I  have  met  with  but  one 
probable  and  seemingly  well-marked  case,  which  I  now  cite,  of  the  so- 
called  cerebral  rheumatism  in  childhood.  A  necropsy,  however,  which 
might  have  definitely  excluded  other  disease  was  not  obtainable. 

A  boy  of  1 2  fell  ill  with  pain  in  the  back,  severe  headache,  and  rigors. 
On  the  fourth  day  of  his  illness  I  saw  him  lying  bathed  in  sour-smelling 
sweat,  profoundly  apathetic,  with  frequent  twitching  of  face  and  fingers ; 
the  respirations  were  60,  the  pulse  180,  and  temperature  106°.  He 
was  roused  only  by  movement  of  his  limbs,  when  he  screamed  with 
evident  pain  ;  but  there  was  little  or  no  visible  swelling,  nor  any  physical 
sign  of  thoracic  mischief.  A  few  years  previously  the  boy  had  had  a 
severe  attack  of  definite  articular  rheumatism  with  occasional  pains,  sub- 
sequently, in  limbs  and  back.  In  spite  of  cold  bathing  sedulously  carried 
out  the  temperature  fell  for  only  a  very  short  time,  and  next  day  death 
followed  on  increasing  coma  with  continued  sweating. 


RHEUMATISM  AND  ARTHRITIS  DEFORMANS.  213 

The  occurrence,  jn  various  parts,  of  the  subcutaneous  fibrous  nodules, 
first  described  by  Meynet  of  Lyons  in  1875  and,  though  noticed  by 
Ilillier,  first  brought  prominently  before  the  English  profession  by  Drs. 
Barlow  and  Warner  at  the  International  Medical  Congress  in  1881,  is 
probably  a  definite  symptom  of  rheumatism,  is  very  generally  associated 
with  arthritis,  and  almost  always  connotes  heart-affection,  which  is  said 
to  be  often  of  a  severe  and  progressive  character.  These  nodules  are 
frequently  very  small,  can  sometimes  be  felt  when  almost  invisible, 
and  may  be  of  any  intermediate  size  up  to  that  of  an  almond.  They 
are  but  rarely  tender  on  pressure,  are  mostly  movable  under  the  skin, 
and  usually  occur  in  the  neighbourhood  of  joints,  especially  about  the 
elbow,  the  knuckles,  the  malleoli  and  the  edge  of  the  patella,  and,  less 
frequently,  over  the  vertebral  spines,  the  iliac  crest,  the  occiput,  and 
various  other  parts.  They  may  be  few  or  many,  and  often  make  their 
appearance  in  successive  crops.  Apparently  they  develop  very  rapidly 
and  often  increase  in  size  after  their  discovery,  but  subside  much  more 
slowly.  I  have,  however,  seen  a  few  cases  of  the  complete  disappearance 
of  many  in  about  a  week.  Their  bruit  of  duration  is  usually  stated  to 
be  from  three  days  to  five  months  or  more.  Pyrexia  is  certainly  no 
regular  accompaniment  of  their  evolution,  and,  according  to  Dr.  Barlow, 
its  presence  is  probably  due  to  some  concomitant  inflammation. 

The  difference  between  observers  as  to  the  frequency  of  these  nodides 
is  probably  the  outcome  of  varying  degrees  of  care  in  the  quest  of  them, 
as  I  have  learnt  from  several  demonstrations,  by  my  colleague  Dr.  Coutts, 
of  minute  nodules  which  I  had  quite  overlooked.  Probably  they  occur 
to  some  extent  in  about  20  per  cent,  of  all  cases  of  acute  rheumatism 
with  heart-disease,  but  large  nodules  are  much  rarer.  Besides  their  pos- 
sibly prognostic  bearing  on  the  progress  of  heart-disease,  these  nodules 
have  a  diagnostic  value  in  sometimes  establishing  the  true  origin  of  other- 
wise doubtful  rheumatic  affection  of  the  heart  and  other  symptoms,  or 
the  rheumatic  association  of  a  given  case  of  chorea.  But,  as  I  have 
already  said,  it  is  known  that  these  fibrous  nodules  are  much  more  often 
seen  in  cases  which  have  suffered  or  are  suffering  from  arthritis. 

In  two  out  of  the  only  four  fatal  cases,  from  my  Hst  of  70,  where 
death  seemed  due  either  to  severe  pleurisy  or  heart-disease  during 
an  acute  attack  of  rheumatism,  there  were  numerous  and  well-marked 
nodules. 

It  must,  however,  be  noted  that  nodules  have,  though  rarely,  been  seen 
where  other  symptoms  of  rheumatism  were  absent.  Dr.  Hadden  has 
reported 1  a  case  in  point  where  there  had  been  neither  arthritis,  chorea, 
nor  heart-disease. 

Pleural  effusion,  single  or  double,  or  pleuro-pneumonia  are  noted  in  at 

1  Clin.  Sue.  Transactions,  vol.  xxiii. 


2  I  4  ACUTE  FEBRILE  DISEASES. 

least  eleven  of  these  cases,  and  in  others  there  were  signs  of  old  pleurisy. 
Extensive  pleurisy  is  a  bad  prognostic  symptom  in  whatever  form  it 
occurs.  Localised  dry  pleurisy  is  very  common;  hut,  apart  from  its 
frequent  tendency  to  recur,  and  thus  to  indicate  a  deep  rheumatic  taint, 
it  has  no  grave  significance. 

Acute  tonsillitis  occurred  in  7  of  the  70  cases  while  in  hospital, 
and  there  was  a  -history  of  previous  and  severe  sore-throat  in  many 
more. 

Erythema  was  observed  in  only  two  of  the  cases,  but  no  inquiry  was 
made  as  to  this  point  while  taking  the  histories ;  and  chorea,  either 
previous  or  concurrent,  was  noted  in  three.  The  well-known  relation- 
ship, however,  between  rheumatism  and  chorea  is  treated  of  under  the 
heading  of  the  latter  disease.  It  must  be  remembered  that  pleurisy, 
pericarditis,  endocarditis,  chorea  and  other  probably  rheumatic  symptoms 
may  be  seen,  from  time  to  time,  in  patients  who  sooner  or  later  after- 
wards have  their  first  attacks  of  articular  rheumatism. 

With  respect  to  the  family  history  of  acute  rheumatism,  although 
careful  inquiry  was  made  in  each  instance,  no  facts,  either  negative  or 
positive,  could  be  gained  in  very  many — a  common  failure  in  hospital 
cases ;  but  there  was  a  perfectly  definite  account  of  one  or  more  sub- 
jects of  this  disease  in  the  immediate  families  of  twenty  of  the  cases,  a 
probable  history  in  many  others,  and  a  satisfactorily  negative  one  in  four. 
Considering  these  statistics,  however,  and,  further,  the  great  frequency 
of  a  history  of  rheumatism  in  the  families  of  rheumatic  patients  in 
private  practice,  the  prevalent  hereditary  character  of  the  rheumatism 
of  childhood  is  well  attested. 

In  the  prognosis  of  rheumatism  we  must  consider  chiefly  the  state 
of  the  heart  and  pericardium  and  other  so-called  complications,  such  as 
pneumonia  and  pleurisy.  When  there  are  marked  signs  of  failing  heart, 
with  or  without  definite  evidence  of  valve  mischief,  extensive  pericarditis 
or  pleurisy,  the  case  is  always  grave,  although,  even  then,  but  rarely  fatal 
in  first  attacks.  In  the  very  rare  instances  of  purulent  pericarditis,  or 
the  somewhat  less  rare  ones  of  empyema,  the  immediate  prognosis  is 
bad ;  and  an  acute  pleural  effusion  on  both  sides  may  be  rapidly  fatal. 
For  the  rest,  there  is  nothing  special  to  children,  in  whom  acute  rheuma- 
tism by  itself  is  of  even  better  immediate  prognosis  than  in  adults.  But, 
seeing  that  the  heart  suffers  so  often  and  so  severely  in  the  rheumatism 
of  childhood,  the  ultimate  forecast  of  most  early  attacks  is  at  the  best 
but  very  doubtful.  A  very  small  proportion  of  children  become  the 
subjects  of  chronic  rheumatism  proper,  by  which  I  mean  more  or  less 
enduring  pains,  stiffness,  swelling,  or  deformity  of  joints  ;  but  many 
suffer  from  marked  and  frequent  recurrence  of  articular  pain  and  swell- 
ing, and  more  from  repeated  flying  pains,  either  neural  or  "  muscular,"  in 


RHEUMATISM  AND  ARTHRITIS  DEFORMANS.  2  I  5 

various  regions.  Torticollis,  too,  must  be  classed  as  an  occasional  sequela 
of  true  rheumatism.  In  the  few  definite  instances  which  I  have  seen 
in  children  of  advanced  and  permanent  deformity  of  joints,  such  as 
is  usually  described  as  "arthritis  deformans"  or  " rheumatic  arthritis," 
there  has  been  no  history  of  primary  acute  articular  rheumatism  or  any 
of  its  usual  accompaniments. 

Emotional  and  other  nerve  disturbances,  such  as  night  terrors  and, 
according  to  Dr.  Goodhart,  enuresis,  are  very  common  in  children  sub- 
ject to  rheumatism ;  and  frequent  headache  also  illustrates  the  neurotic 
relationships  of  the  disease,  which  are  often  so  marked  in  adults  as 
well. 

The  treatment  of  rheumatic  fever  in  childhood  has  no  claim  to  detailed 
special  consideration.  For  the  acute  manifestations,  as  long  as  the 
heart  is  working  well,  even  though  there  may  be  abnormal  auscultatory 
signs,  salicin  or  the  salicylate  of  soda  should  be  given.  These  drugs, 
and  especially  the  salicylate,  are  successful,  as  in  adult  cases,  in  propor- 
tion to  the  severity  of  the  pain  and  the  height  of  the  fever ;  and,  accord- 
ing to  the  best  clinical  experience,  seem,  valuable  though  they  are,  to  be 
merely  symptomatic  remedies.  But,  considering  that  in  children  both 
these  symptoms  are  often  slight  and  evanescent,  they  are  by  no  means  so 
often  required  as  in  the  case  of  adults  ;  and  further,  in  view  of  the  more 
common  cardiac  troubles  of  childhood,  they  are  often,  in  my  opinion  as 
in  that  of  some  others,  inadmissible.  I  am  sure  that  in  several  cases  in 
adults  I  have  known  the  heart  functions  impaired  and  improved  by  the 
alternate  giving  and  withholding  of  salicylate  of  soda,  or,  in  some 
instances,  of  salicin,  which  was  less  often  tried.  In  such  a  difficulty 
pain  and  restlessness,  and  other  cardiac  symptoms  as  well,  may  be  much 
relieved  by  small  and  repeated  doses  of  opium ;  or,  when  the  joint-affection 
is  at  all  severe,  small  blisters  may  be  used,  frequently  with  good  effect. 
In  these  cases,  as  well  as  in  others  which  are  slight  and  relapsing,  I  still 
think  that  there  may  be  at  least  symptomatic  relief  from  giving,  as  I 
often  do,  bicarbonate  of  potash  or  other  alkaline  medicine,  according 
to  older  custom  ;  and  the  more  chronic  or  recurrent  any  rheumatic  symp- 
toms without  fever  are,  the  more  should  we  insist  on  tonic  treatment, 
with  passive  movement  of  the  joints  and  systematic  rubbing.  The  diet 
during  the  acute  attack  should  be  milk  with  some  farina.  During  con- 
valescence it  should  be  light,  but,  especially  when  there  is  much  anaemia, 
not  necessarily  without  meat.  If  lithates  appear  to  any  extent  in  the 
urine,  fever  diet  should  be  returned  to  for  a  while.  The  child  should 
of  course  be  kept  in  bed  until  the  attack  is  over,  and  carefully  preserved 
from  chill  at  all  times,  whether  well  or  ill.  It  is,  in  my  opinion,  neither 
necessary  nor  advisable  to  force  either  a  child  or  an  adult  to  lie  between 
blankets  ;  for  I  have  often  seen  much  discomfort,  increased  sweating  and 


2  I  6  ACUTE  FEBRILE  DISEASES. 

cutaneous  irritation  produced  thereby.     Arsenic,  iron  and  cod-liver  oil 
are  all  very  useful  medicines  in  convalescence. 

The  treatment  of  the  cardiac  troubles  of  Eheumatism  is  considered 
under  the  heading  of  Heart-disease. 


Arthritis  Deformans. 

It  is  necessary  to  treat  shortly  of  this  disease,  for,  although  not  frequent 
in  childhood,  it  is  scarcely  as  rare  as  might  be  believed  from  its  usual 
omission  from  the  text-books.  Some  cases  under  two  years  old  have 
been  reported.  Owing  to  its  clinical  likenesses  and  still  greater  contrasts 
to  rheumatism  it  seems  practically  better  to  deal  with  it  here  than 
under  the  possibly  more  appropriate  heading  of  diseases  of  the  nervous 
system. 

In  all  essential  characteristics  "arthritis  deformans"  or,  as  many  style 
it,  "  rheumatoid  arthritis  "  is  the  same  in  children  as  in  adults,  and  appears 
to  arise  in  similar  conditions.  Its  origin  is  as  a  rule  insidious,  without 
fever ;  and  pain  with  stiffness  in  the  joints  is  at  first  a  much  more  pro- 
minent symptom  than  swelling,  which  indeed  for  a  while  may  be  un- 
observed. Some  cases,  however,  begin  more  or  less  acutely  with  an  attack 
of  joint-pains  of  definite  date.  The  hands  are  usually  first  affected  in 
the  small  joints,  and  much  time  may  pass  without  involvement  of  the 
larger  joints  of  the  extremities.  The  larger  joints  however,  judging  from 
the  cases  I  have  seen  and  from  those  reported  by  others,  are  liable  to  be 
affected  sooner  or  later ;  and  not  only  the  wrists  and  ankles  but  also  the 
knees,  elbows,  shoulders  and  hips  may  be  quite  disabled.  The  swelling 
of  the  joints  is  followed  by  displacement  of  the  bones ;  and,  after  a  period 
Avhen  much  grating  and  creaking  on  movement  may  be  felt  or  heard, 
permanent  ankylosis  may  at  last  take  place.  I  had  a  case  of  a  girl,  now 
under  observation  at  Westminster  Hospital  in  the  ward  for  Incurables, 
in  whom  the  symptoms  began  at  the  age  of  1 1  years  with  pain,  swelling, 
and  redness  of  the  right  knee  and  right  ankle  soon  after  she  had  been  wet 
through  two  or  three  times.  The  knee  soon  became  semiflexed,  and  the 
swelling  and  pain  increased.  Gradually  most  of  her  joints  were  affected 
and  distorted,  the  knees  becoming  flexed  and  the  feet  permanently  everted 
almost  at  right  angles  to  the  leg.  The  patient's  paternal  aunt  and  grand- 
mother were  similarly  affected,  and  her  father  had  had  rheumatic  fever 
when  he  was  nineteen.  There  was  also  a  probable  history  of  acute 
rheumatism  in  other  relatives  not  of  the  immediate  family. 

A  marked  characteristic  of  this  disease,  well  shown  in  the  case  above 
referred  to,  is  the  atrophy  of  the  muscles  in  connexion  with  the  affected 
joints  :  a  condition  quite  inexplicable  by  the  theory  of  disuse,  and  un- 
paralleled in  other  joint-affections,  always  excepting  those  which  occur  in 


RHEUMATISM   AND  ARTHRITIS  DEFORMANS.  2\J 

association  with  ether  nervous  phenomena  such  as  the  symptoms  of  tabes 
dorsalis. 

The  anatomical  condition  of  the  joints,  as  far  as  clinical  examination 
shows,  is  apparently  the  same  as  in  the  adult  disease.  This  is  marked 
by  chronic  inflammation  affecting  all  the  joint  structures,  leading  to 
erosion  of  the  cartilages,  bony  outgrowths  from  their  edges,  and  at  last  to 
considerable  absorption  of  the  ends  of  the  bones  and  fibrous  ankylosis. 

In  the  four  or  five  cases  I  have  seen  of  the  disease  before  puberty 
there  was  mostly  a  history  of  acute  rheumatism  in  the  family,  no  febrile 
movement  with  the  attack,  and  no  evidence  of  any  cardiac  affection. 
Some  cases,  however,  as  recorded  by  Sir  A.  Garrod  and  others,  and  as 
illustrated  by  the  instance  above  quoted,  appear  to  begin  acutely,  and 
sometimes  with  fever.  Mr.  Hutchinson  has  shown  that  the  joint-disease 
may  anticipate  all  other  symptoms  for  some  time.  That  "  arthritis 
deformans "  may  have  some  more  or  less  remote  alliance  with  true 
rheumatism  cannot  be  denied.  Some  few  cases  are  preceded  by  definite 
attacks  of  the  latter  disease ;  but  in  so  common  an  affection  as  acute 
rheumatism  this  sequel  is  extremely  rare. 

The  favourite  subjects  of  the  adult  disease  are  seemingly  the  ill- 
nourished  and  anaemic,  the  physically  exhausted,  and  the  mentally 
depressed.  The  most  common  excitants  are,  with  equal  or  greater 
probability,  damp  and  cold.  As  far  as  my  small  experience  of  the 
disease  in  children  has  taught  me  anything,  I  would  say  that  a  neurotic 
constitution  and  exposure  to  cold  and  damp  are  prominent  antecedents. 
In  early  cases  the  good  effects  of  generous  diet,  tonic  treatment,  warmth, 
and  dryness  of  climate  are  very  marked  at  all  ages. 

The  important  observations  of  many,  tending  to  show  that  in  the 
adult  disease  the  joints  most  used  are  the  most  likely  to  suffer  early 
and  severely,  cannot,  as  far  as  I  know,  be  regarded  as  markedly  applicable 
to  the  affection  as  seen  in  childhood.  The  joints  of  the  toes  however, 
with  the  exception  of  the  ball  of  the  great  toe,  seem  as  a  rule  to  escape, 
at  least  for  a  very  long  time,  in  all  forms  of  the  affection. 

The  disease  in  adults  is  liable,  as  is  well  known,  to  periods  of 
symptomatic  latency,  and  to  exacerbations  of  pain  and  swelling  in  vary- 
ing extent  and  degree.  Sometimes  a  few  joints  only  are  affected,  and, 
after  more  or  less  damage  done,  no  recurrence  takes  place.  I  have  not 
been  able  to  find  any  published  data  on  which  to  ground  any  practical 
rules  of  prognosis  as  regards  the  disease  in  childhood. 

The  earlier  the  case  is  recognised,  and  treatment  undertaken,  the  better 
the  chance  of  arrest  or  approximate  cure.  Arguing  from  adult  cases, 
we  are  justified  in  looking  for  improvement  from  good  nutrition, 
warmth  and  dry  air.  In  severe  cases  I  have  seen  marked  benefit  result 
from  the  simple  addition  of  arsenic  to  the  other  therapeutic  means  used. 


2  I  8  ACUTE  FEBRILE  DISEASES. 

I  am  of  opinion  that  this  drug  should  be  persistently  given  from  the 
outset.  Cod-liver  oil  is  also  valuable,  and  probably  iron  as  well. 
If  there  be  no  great  subsequent  pain,  passive  movement  of  the  joint 
and  daily  prolonged  rubbing  of  the  limbs  should  be  part  of  the  routine. 
The  patient  should  always  be  encouraged  to  use  the  joints  as  much  as 
possible.  When  pain  is  considerable  guaiacum  is  sometimes  useful ; 
and,  although  I  would  only  advise  its  temporary  use,  a  combination  of 
colchicum,  potassium  iodide  and  bicarbonate  of  potash  has  not  seldom, 
in  my  experience,  seemed  to  give  much  relief  to  the  patient's  feelings. 
Counter-irritation  over  the  joints,  by  means  of  the  liniment  of  iodine, 
may  be  of  some  use  in  early  cases.  If  possible,  the  sufferer  shotdd  be 
sent  in  the  winter  to  such  a  climate  as  Egypt.  In  England  the  treat- 
ment at  Bath  at  any  time  of  the  year  seems  worthy  of  trial ;  considerable 
benefit  having  appeared  to  me  to  result  therefrom  in  two  cases  below 
the  age  of  puberty,  as  well  as  in  several  adults. 


CHAPTER  IX. 

WHOOPING-COUGH. 

By  this  name  is  denoted  a  peculiar  spasmodic  cough,  occurring  in  paroxysms 
of  sometimes  excessive  frequency,  often  associated  with  catarrh  both 
bronchial  and  nasal,  and  largely  tending  to  spread  among  children. 

The  whooping  inspiratory  sound  so  often  heard  is  a  result  of  laryngeal 
spasm  coincident  with  the  inrush  of  air  to  the  lungs,  which  have  been 
emptied  by  the  violence  of  the  expiratory  paroxysm.  This  is,  as  a  rule, 
absent  in  the  earliest  period,  may  never  appear  at  all,  continues  some- 
times long  after  the  affection  has  ceased  to  be  communicable,  and  recurs 
frequently  for  months,  or  occasionally  for  years,  with  every  fresh  attack 
of  catarrh.  The  essential  clinical  mark  of  the  affection  is  the  sudden 
onset  of  severe  paroxysmal  coughing,  with  varying  degrees  of  suffocative 
symptoms  and  frequent  vomiting,  rather  than  the  laryngeal  noise  which 
so  often  follows  of  necessity  on  expiratory  violence.  During  the  recent 
epidemics  of  influenza  it  was  not  uncommon,  especially  in  the  earliest 
stage  of  the  disease,  to  note  a  paroxysmal  and  suffocative  cough  accom- 
panied by  well-marked  whooping  in  no  way  distinguishable  from  this 
familiar  symptom  of  whooping-cough  in  childhood  ;  and  it  is  certain  that 
such  a  sound  is  not  confined  to  these  diseases,  but  not  infrequently 
occurs  with  violent  coughing  otherwise  and  suddenly  excited. 

Objections  to  the  generally  accepted   view  of    the   germ-origin  and 


WHOOPING-COUGH.  2  19 

specificity  of  all  cases  of  cough  with  whooping'  have  occurred  to  many 
thoughtful  ohservers,  owing  to  the  differences  presented,  in  many  in- 
stances, from  the  usual  characters  of  most  affections  of  the  infectious 
class.  It  is  not  to  be  doubted  that  clinically  typical  and  uncomplicated 
whooping-cough  is  often  quite  free  from  fever  from  first  to  last,  and  is 
accompanied  by  no  other  sign  whatever  of  illness.  At  the  outset  indeed, 
before  any  characteristic  cough  is  heard  and  when  the  existence  of 
catarrhal  symptoms  only  makes  an  initial  diagnosis  impossible,  ther- 
mometric  observations  of  temperature  are  rarely  made ;  and  there  can 
be  no  justification  for  the  positive  statement,  re-iterated  by  most  writers, 
that  an  early  febrile  stage  is  the  rule.  At  the  height  of  the  disease, 
moreover,  there  is  no  fever  unless  there  be  pulmonary  or  other  com- 
plications ;  and  I  have  amply  satisfied  myself,  by  searching  inquiry  into 
the  history  of  very  many  cases,  that  there  is  probably  no  initial  fever 
or  even  malaise  in  a  large  number.  Those  who  are  feverish  and  ill 
at  the  beginning  and,  often,  for  some  weeks  afterwards  are  mostly 
infants  or  quite  young  children  ;  and  these  are  nearly  always  the  subjects 
of  more  or  less  extensive  bronchial  catarrh  or  broncho-pneumonia.  The 
purest  examples  of  whooping-cough  are  non-febrile  cases  in  children 
beyond  infancy  ;  and  it  is  in  these  that  the  disease  is  most  justly  studied. 
In  such  cases  the  interparoxysmal  state  is  usually  unaccompanied  by 
any  abnormal  physical  signs  in  the  chest. 

The  course  of  whooping-cough  is  of  very  variable  duration,  as  any  one 
may  learn  from  experience  without  referring  to  the  widely  discrepant 
statements  made  on  this  head  by  writers.  The  usual  division  of  the 
disease  into  three  stages  is  artificial,  and  useless  for  practical  purposes ; 
for  the  so-called  first  stage  can  be  but  rarely  studied  and  is  very  variously 
described,  the  second,  with  the  characteristic  cough,  may  set  in  at  very 
different  periods  and  last  indefinitely,  and  the  third  is  nothing  other 
than  gradual  convalescence.  Again,  it  is  not  by  any  means  rare  to 
find  single  instances  of  what  is  clinically  whooping-cough,  and  quite 
indistinguishable  from  contagious  cases,  occurring  in  families  where  the 
other  children  have  not  previously  suffered.  I  have  frequently  estab- 
lished this  fact  by  observation  and  inquiry  extending  over  some  months, 
so  as  to  more  than  include  the  longest  alleged  period  of  incubation ;  and 
at  Shadwell  Hospital,  where  whooping-cough  for  many  years  was  formerly 
admitted  into  the  general  wards,  spreading  of  the  disease  but  very  rarely 
occurred.  The  striking  difference  in  this  respect  between  the  spread 
of  whooping-cough  and  measles,  which  has  been  noted  by  Henoch  and 
others  and  observed  though  not  recorded  by  many  more,  is  not  to  be 
accounted  for  by  more  children  being  protected  by  previous  whooping- 
cough.  Our  extensive  records  at  Shadwell  Hospital  show  that  less  than 
23  per  cent,  of  children  admitted  under  six  years  old — the  favourite 


2  20  ACUTE  FEBRILE  DISEASES. 

period  for  whooping-cough — had  previously  suffered  from  that  disease, 
while  34  per  cent,  had  had  measles.  Some  have  endeavoured  to  explain 
the  infrequent  spread  of  whooping-cough  in  wards  by  the  contention 
that  actual  contact  or  very  close  proximity  is  necessary  for  the  contagium 
to  work — a  condition  which  is  more  likely  to  obtain  when  the  children 
are  up  and  about  than  when  separated  by  inter-cubicular  spaces ;  but  it 
must  be  remembered  that  many  children  in  a  ward  are  not  kept  in  bed ; 
that  when  whooping-cough  does  spread  among  children  in  bed  it  spreads 
sporadical^ ,  not  from  neighbour  to  neighbour ;  and,  further,  that  a  very 
large  amount  of  the  evidence  of  the  contagiousness  of  the  disease  falls 
to  the  ground  without  the  assumption  of  the  greatest  diffusibility  and 
subtlest  activity  of  the  poisonous  principle.  But  none  of  these  facts 
seem  to  me  to  weigh  materially  against  the  view  of  the  germ-origin  of 
the  cases  of  whooping-cough  which  are  confessedly  contagious,  especially 
in  the  light  of  our  extended  conception  of  micro-organic  pathology ;  for 
neither  febrility,  nor  definite  course,  nor  striking  contagiousness  apart 
from  inoculation  are  necessary  elements  in  nricrophytic  disease.  I  am 
strongly  inclined  to  believe  that,  in  what  we  must  clinically  and  for 
practical  purposes  call  whooping-cough,  Ave  have  really  to  do  with  many 
cases  which  are  neither  specific  nor  catching,  albeit  at  first  virtually 
indistinguishable  from  those  which  are ;  and  I  further  think  that, 
although  true  contagion  by  means  of  the  sputa  or  other  emanations  is 
scarcely  to  be  questioned  in  many  instances,  the  spread  of  whooping- 
cough  as  a  whole  from  the  sick  to  the  unprotected  is  far  less  ready 
and  much  more  sporadic  or  fitful  than  that  of  measles  and  other 
exanthems.  In  other  words,  I  believe  that  a  paroxysmal  cough  with 
whooping  may  be  engrafted  as  a  purely  nervous  incident  on  ordinary 
catarrh,  apart  from  the  influence  of  any  specific  organism ;  and,  further, 
that  in  the  clearly  contagious  and  epidemic  catarrh,  which  we  recognise 
as  "typical"  whooping-cough,  there  may  be  very  varying  degrees  of 
infective  power.  The  great  difficulty  of  regarding  "whooping-cough" 
as  always  one  and  the  same  disease  is  also  somewhat  enhanced  by  its 
frequent  and  immediate  sequence  on,  or  development  out  of,  the  catarrh 
of  measles,  even  when  a  fresh  source  of  infection  can  be  with  all  probability 
excluded.  Among  many  other  striking  instances  of  this  concurrence  with 
catarrh  I  have  seen  whooping-cough  follow  on  broncho-pneumonia  in  two 
children  suffering  from  scarlatina,  who  were  strictly  isolated,  and  for  several 
weeks  inhabited  alternately  two  rooms  daily  ventilated  by  widely  opene  d 
windows  and  frequently  sprayed  with  carbolised  vapour. 

As  to  the  contagious  form  of  whooping-cough,  there  is  no  direct 
evidence  as  yet  generally  recognised  of  a  specific  germ,  however  pro- 
bable its  existence  may  be,  although  certain  bacilli  have  been  found  and 
believed  by  some  to  be  pathogenic ;  nor  is  there  any  agreement  among 


WHOOPING-COUGH.  22  1 

authorities  as  to  the  period  of  incubation.  About  fourteen  days  has 
been  established  with  much  probability  in  some  cases ;  but,  if  we  were 
to  exclude  instances  where  the  incubative  period  must  have  been  much 
shorter  or  much  longer,  the  evidence  of  any  contagion  at  all  would  be 
considerably  weakened.  We  must  believe,  however,  at  present,  after  due 
consideration  of  hard  facts  and  conflicting  commentaries,  that  there  are 
contagious  catarrhs,  with  perhaps  diverse  microphytic  sources,  which 
specially  affect  the  upper  air -passages  and  cause  an  exceptionally 
paroxysmal  and  violent  cough  usually  entailing  the  characteristic  whoop  ; 
and  that  the  contagium  is  probably  contained  in  the  sputa  and  breath 
of  the  sufferers.  For  practical  purposes  we  should  therefore  isolate 
patients  with  "  whooping-cough "  as  long  as  there  are  distinct  signs  of 
nasal  or  bronchial  catarrh ;  and,  in  all  cases,  empirically,  (for  we  have 
absolutely  no  knowledge  of  the  limits  of  the  infective  period)  for  six 
weeks.  If  there  be,  as  I  believe,  very  numerous  cases  of  non-contagious 
whooping-cough,  we  have  certainly  no  means  of  diagnosing  them  at  the 
beginning ;  we  must,  therefore,  practically  regard  all  cases  at  first  as 
coming  under  the  category  of  infectious  disease.  But  in  instances,  such 
as  I  have  frequently  met  with,  where  a  child  whoops  with  every  fresh 
catarrh  for  months  or  even  sometimes  for  years,  we  may  usually  be 
certain  of  their  harmlessness. 

The  paroxysmal  and  suddenly  explosive  nature  of  the  cough  will,  in 
many  cases,  tell  the  experienced  observer  of  the  nature  of  the  affection  to 
come,  even  before  any  suffocative  or  severe  symptoms  set  in  or  any 
whoop  be  heard  ;  and  the  diagnosis  is  much  strengthened,  in  spite  of  the 
absence  of  evidence  of  laryngeal  or  bronchial  catarrh,  when  the  cough  is 
very  frequent,  especially  at  night.  The  prevalence  of  an  epidemic,  as  in 
other  cases,  may  give  valuable  aid ;  but  this  occurrence  is  far  less  frequent 
and  definite  than  in  most  other  contagious  diseases.  In  the  established 
disease,  a  full  symptomatic  description  of  which  I  purposely  omit  as- 
familiar  to  my  readers,  great  diagnostic  stress  must  be  laid  on  the 
redness  of  the  face,  which  is  marked  even  at  the  beginning  of  the 
paroxysms  of  repeated  coughing ;  and  on  the  puffy  and  venously  con- 
gested face  of  many  of  the  sufferers  even  during  their  inter-paroxysmal 
states. 

Whooping-cough,  as  a  whole,  is  most  frequent  in  children  over  six 
months  and  under  six  or  seven  years  old.  The  second  and  third  year& 
are  perhaps  its  favourites.  From  the  exhaustion  due  to  the  frequent 
coughing  and  vomiting,  and  the  frequent  co-existence  of  extensive  bron- 
chitis, broncho- pneumonia  and  pulmonary  collapse,  the  mortality  of  the 
disease  in  children  under  two  years  old  is  enormous.  Haemorrhages 
into  the  conjunctivas,  epistaxis,  haemoptysis  from  faucial  or  laryngeal 
sources,  rupture  of  the  ear-drums,  ulceration  near  the  frasnum  linguae- 


22  2  ACUTE  FEBRILE  DISEASES- 

from  friction  with  the  teeth,  and  convulsive  seizures  may  be  more  or 
less  frequent  incidents  of  the  disease ;  severe  headache  is  very  often 
complained  of ;  and  hoarseness  is  not  uncommon.  The  cough  is  apt  to 
be  especially  severe  and  frequent  at  night.  In  some  few  cases  meningeal 
hsemorrhage  has  been  observed  as  the  probable  result  of  a  violent 
paroxysm ;  and  Henoch  reports  a  case  of  hemiplegia  referable  to  a 
similarly  caused  cerebral  haemorrhage. 

Diarrhoea  with  much  mucus  in  the  stools,  indicative  of  intestinal 
catarrh,  is  doubtless  frequently  seen  with  whooping-cough,  and  is  pro- 
bably a  part  of  general  catarrh ;  but,  having  for  many  years  made 
special  inquiries  and  observations  on  this  point,  I  am  convinced  that  in 
the  majority  of  cases  intestinal  disorder  plays  no  part. 

Convulsions,  if  frequently  repeated,  are  usually  of  serious  import.  A 
previously  convulsive  child,  however,  will  have  its  fits  more  frequently 
in  whooping-cough ;  and  the  paroxysms  of  cough  are,  in  their  turn,  most 
readily  excited  by  the  slightest  disturbance  in  convulsive  or  very  nervous 
children.  The  nervous  element  in  whooping-cough,  indeed,  is  not  only 
always  prominent  but  also  may  be  considered,  apart  from  the  question 
of  the  nature  and  mode  of  contagion,  as  the  very  essence  of  the  affec- 
tion. Space  forbids  me  to  say  more  on  this  subject,  which  has  been  so 
thoroughly  treated  by  Sturges.  Some  convulsions  seem  directly  induced 
by  the  suffocative  paroxysm,  and  others  by  the  subsequent  exhaustion. 
Those  which  may  be  due  to  embolism  or  thrombosis  of  the  cerebral 
veins  or  sinuses  will  be  of  considerable  prognostic  gravity,  and  their 
nature  may  be  suspected  from  concomitant  paralysis  or  a  strictly  unilateral 
distribution. 

The  co-existence  of  other  diseases,  especially  of  rickets  with  its  yielding- 
thorax,  or  of  tuberculosis,  largely  aggravates  the  dangers  of  Avhooping- 
cough ;  and  it  must  never  be  forgotten  that  a  vast  number  of  cases  of 
chronic  pulmonary  disease,  tubercular  and  otherwise,  with  enlarged  and 
cheesy  bronchial  glands,  seem  to  take  their  origin  from  this  affection. 
Instances  of  chronic  bronchitis,  broncho-pneumonia,  emphysema,  asthma, 
phthisis  and  other  disorders,  where  the  history  is  given  of  continuously 
bad  health  after  whooping-cougb,  are  simply  legion. 

We  have  seen  that  the  duration  of  the  disease  is  very  indefinite 
because  of  its  probably  varying  origin.  Perhaps  in  the  truly  contagious 
cases  an  average  may  be  struck  of  about  three  months,  from  the  onset 
to  the  disappearance  of  all  incidental  symptoms ;  but  the  contagious 
period  is  probably  much  shorter.  It  has  already  been  remarked  that 
whooping-cough  and  measles  frequently  occur  in  very  close  connexion ; 
and  I  would  further  state,  after  extensive  inquiry  on  this  point,  that  in 
an  overwhelming  majority  of  cases  of  such  connexion  the  whooping- 
cough  is  sequent  upon  measles.     In  many  instances  of  this  kind  the 


WHOOPING-COUGH.  2^3 

spasmodic  cough  is  doubtless  a  nervous  epi-plienonienon  in  no  way 
connected  with  specific  infection ;  and  this  consideration,  together  with 
the  fact  of  whooping-cough  being  far  more  common  in  girls  than 
boys  after  the  first  few  years  of  life,  points  strongly  to  the  conclusion 
that  in  so-called  whooping-cough  Ave  have  not  always  to  do  with  one 
and  the  same  disease. 

The  prognosis  in  whooping-cough  depends  on  the  facts  of  the  indivi- 
dual case,  and  little  can  be  gained  by  generalisation.  Uncomplicated 
cases  are  seldom  fatal  except  in  children  under  two  years  old,  many  of 
whom  die  in  or  from  convulsions  or  from  exhaustion.  For  the  rest,  the 
main  dangers  lie  in  pulmonary  complications,  coincident  rickets,  and  the 
untoward  sequela?  above  mentioned. 

Treatment  for  this  disease  is  as  multiform  as  it  is  important.  Al- 
though we  have  certainly  no  means  at  present  of  cutting  short  the 
attack  or  of  antagonizing  the  action  of  the  germs  which  we  believe  to 
be  the  source  of  many  cases,  we  can  often  successfully  lessen  its  most 
troublesome  symptoms  and  palliate  some  of  its  complications. 

Immediate  isolation  of  children  suspected  of  whooping-cough  shoidd 
be  ordered ;  and  especial  care  should  be  taken  to  remove  infants  and 
younger  children  from  possible  sources  of  infection,  for  in  these  the  most 
untoward  results  are  to  be  dreaded.  The  patient  should  be  kept  indoors 
in  an  equable  temperature  of  about  630  F.,  for  chill  is  especially  liable  to 
induce  a  paroxysm  of  coughing ;  but  it  is  equally  important  that  the 
room  should  not  be  too  hot  and  that  the  air  should  be  frequently  renewed. 
For  this  purpose  a  frequent  change  between  two  rooms  is  to  be  advised. 
In  uncomplicated  cases,  indeed,  our  chief  effort  should  be  to  prevent  all 
known  excitants  of  cough,  among  which  vitiated  air  is  prominent.  The 
patient  should  also  be  kept  quiet,  and  free  from  excitement  which,  un- 
questionably, often  determines  a  paroxysm.  When  there  is  fever,  and 
especially  when  there  is  marked  bronchial  or  pulmonary  complication, 
the  patient  should  be  confined  to  bed.  For  the  purpose  of  antagonizing 
the  cause  of  the  disease  or  checking  cough  many  drugs  have  been  used 
both  theoretically  and  empirically.  My  experience  is  that  we  can  often 
control  the  cough  with  marked  success  by  many  different  medicines,  but 
that  there  is  no  one  drug  of  which  we  can  predict  any  considerable 
degree  of  efficacy  in  any  given  case.  Inhalation  of  diluted  carbolic  acid 
spray  or  of  other  tar-products,  and  of  antiseptic  remedies  generally,  widely 
practised  and  much  lauded  by  many,  I  have  tried  in  many  cases ;  some- 
times, as  in  other  modes  of  treatment,  with  apparent  success,  and  some- 
times with  signal  failure.  In  several  early  cases,  recalcitrant  to  other 
remedies,  I  have  ordered  constant  impregnation  of  the  air  of  the  room 
with  carbolic  acid  or  creasote  by  means  of  the  steam-draft  apparatus,  on 
the  plan  of  Dr.  Robert  Lee ;  but  have  rarely  seen  any  notable  result. 


224  ACUTE  FEBRILE  DISEASES. 

Ill  the  later  stages  equal  improvement  may  apparently  follow  on  very 
diverse  remedies.  Among  the  innumerable  drugs  recommended,  either  as 
specifies  or  palliative  remedies,  I  think  I  have  seen  benefit  arise  in  different 
cases  from  the  bromides,  chloral,  cannabis  indica,  and  possibly  some- 
times from  the  extract  or  tincture  of  belladonna ;  but  as  regards  the  latter 
drug,  as  well  as  the  solution  of  atropia,  I  am  convinced,  by  very  numerous 
trials  to  which  out  of  deference  to  authority  I  have  again  and  again 
recurred  after  repeated  disappointments,  that  it  ranks  very  low  even  as 
a  palliative ;  and  I  have  frequently  pushed  it  to  the  production  of  its 
physiological  effects.  For  many  years  I  have  found  no  remedy  in 
uncomplicated  whooping-cough  so  often  useful  as  opium,  in  the  form 
either  of  the  compound  tincture  of  camphor  or  of  laudanum ;  and  I 
now  scarcely  ever  treat  a  case  of  ordinary  whooping-cough  without  it. 
This  drug  can  be  given  with  safety,  in  very  small  doses,  even  to  infants ; 
and  the  only  contra-indications  are  dyspnoea  from  pulmonary  obstruction 
and  evidence  of  renal  failure.  By  opium,  far  more  than  any  other  remedy, 
both  the  force  and  frequency  of  the  paroxysms  of  whooping-cough  are 
often  markedly  lessened.  I  do  not  think  that  quinine  in  any  dose  has 
any  effect  on  the  course  or  symptoms  of  the  disease.  For  the  frequently 
accompanying  bronchitis  and  broncho-pneumonia  the  ordinary  treatment 
proper  to  these  affections  is  applicable.  The  bromides  are  often  useful 
in  neurotic,  and  especially  in  convulsive,  children. 

After  improvement  has  set  in,  as  evidenced  by  a  notable  reduction  of 
the  number  of  paroxysms,  and  when  there  is  but  little  remaining  bron- 
chial catarrh,  as  shown  by  physical  examination,  the  patient  may  be 
allowed  to  go  out,  being  kept  away  from  other  children ;  and  a  change  of 
scene  or,  it  may  be,  a  change  of  air  will  often  be  followed  by  an  almost 
sudden  cessation  of  all  symptoms,  as  I  have  personally  observed  in  several 
instances.  I  have,  further,  sometimes  seen  apparently  ingravescent  and 
early  cases  of  whooping-cough  almost  suddenly  recover,  not  only  with 
change  of  place,  but  also  even  while  remaining  at  home  or  in  the  hospital 
ward.  Many  instances  of  this  have  been  characterized  by  some  pul- 
monary trouble  for  an  indefinite  and  sometimes  long  time  before  the 
paroxysmal  cough,  with  reddening  of  the  face  and  whoop,  has  been 
observed;  and  are  perhaps  to  be  regarded  as  belonging  to  the  non- 
specific group  alluded  to  above.  The  nervous  element  in  whooping-cough, 
evidenced  by  the  paroxysmal  cough  and  its  frequent  excitement  and 
stoppage  by  psychical  means,  is,  as  we  have  seen,  often  very  prominent ; 
and  in  protracted  and  recurrent  cases  is  probably  the  only  fact  to  be 
dealt  with.  There  is  abundant  evidence  that  a  child  may  have  occa- 
sionally typical  paroxysms  of  cough,  and  be  perfectly  well  and  free  from 
contagious  influence  on  others ;  but  our  ignorance  of  the  time-limits  of 
contagion  gives  rise  to  a  vast  practical  difficulty  in  deciding  on  the 


\VHOOPING-CO(J<;H.  22  5 

necessary  period  of  isolation  for  the  protection  of  others,  and  we  are  thus 
driven  back  on  the  barest  empiricism.  My  practice,  believing  though 
I  do  that  the  contagious  period  is  probably  not  more  than  two  or  three 
weeks,  is  to  isolate  all  patients  for  six  weeks  ;  and,  after  that  term,  to  let 
them  go  free  whether  they  whoop  or  not,  provided  always  that  they  feel 
well  and  have  neither  symptoms  of  nasal  catarrh  nor  any  expectoration. 
We  may  hope,  if  not  trust,  that  the  time  may  come  when  micro-biological 
investigation  will  supply  us  with  means  towards  accurate  diagnosis, 
scientific  prophylaxis,  and  possibly  efficacious  treatment  of  this  familiar 
though  still  indefinite  disease. 


(    226a   ) 


APPENDIX  TO  SECTION  III. 


ABSTRACT  op  the  Conclusions  given  in  the  "  Report  op  a  Committee 
appointed  by  the  clinical  society  op  london  to  investigate 
the  Periods  op  Incubation  and  Contagiousness  op  certain  In- 
fectious Diseases."  Supplement  to  Vol.  XXV,  of  the  Clinical  Society's 
Transactions.     London  :   Longmans,  Green  &  Co. 

Small-pox. 

Incubation  Period. — The  interval  from  exposure  to  the  appearance  of  the  initial 
symptoms  is  commonly  12  days  ;  but  not  infrequently  it  is  a  day  more  or  a  day 
less.  Occasionally  it  is  as  short  as  9  or  10  days,  and  sometimes  as  long  as  14  or 
15  days. 

Infectious  Period. — The  patient  remains  infectious  from  the  onset  of  the  initial 
symptoms  until  all  scabs  have  cleared  off.  The  infection  is,  however,  much 
more  intense  during  the  height  of  the  active  stage  than  during  the  initial  illness. 

Isolation  may,  for  the  reason  just  given,  be  practised  as  late  as  the  time  of  the 
appearance  of  the  rash  with  some  expectation  that  the  spread  of  the  disease  may 
thus  be  checked.  The  infection  is  easily  carried  in  clothes,  and  in  the  hair  of  a 
person  in  attendance  on  a  small-pox  patient. 

Chicken-pox. 

Incubation  Period— The  incubation  period  is  usually  14  days,  but  may  be  a  day 
less  or  4  or  5  days  more. 

Infectious  Period. — A  patient  is  infectious  at  least  as  soon  as  the  rash 
appears,  and  remains  so  during  convalescence.  The  infection  can  be  conveyed 
by  fomites. 

Measles. 

Incubation  Period.— The  most  usual  period  is  9  or  10  clays.  Occasionally  the 
period  is  as  short  as  5  or  even  4  days,  and  sometimes  as  long  as  14.  A  susceptible 
person  who  has  been  exposed  to  infection  must  be  found  free  from  fever  and 
catarrh  at  the  end  of  a  fortnight  before  it  can  be  said  that  the  disease  has  not 
been  contracted. 

Infectious  Period. — A  patient  is  very  infectious  during  the  prodromal  stage,  and, 
probably,  not  less  so  during  the  acute  attack  ;  thereafter  infectivity  declines 
rapidly  and  has  ceased  altogether  three  weeks  after  the  rash.  As  it  is  probable 
that  the  infection  can  be  retained,  for  a  short  time  at  least,  in  fomites,  it  is 
necessary  to  practise  disinfection  before  terminating  the  period  of  isolation, 
which  should  be  for  three  weeks  after  the  appearance  of  the  rash. 

Rubeola  (Rubella  or  "  German  Measles  "). 

Incubation  Period.— The  most  frequent  period  is,  probably  16  to  18  days  ;  but 
it  may  be  as  long  as  2 1  days  or  as  short  as  8,  possibly  even  less.  In  62  out  of  69 
cases  it  was  some  period  between  12  and  18  days. 

P   2 


226b  APPENDIX    TO    SECTION    III. 

Infectious  Period. — A  patient  begins  to  be  infectious  2  or  3  days  before  the 
rash  appears,  and  continues  so  during  the  height  of  the  disorder.  Infection 
rapidly  declines  thereafter,  and  ceases  in  a  week  in  mild  cases  ;  but  it  probably 
persists  in  cases  where  desquamation  occurs  until  that  process  is  over. 

Quarantine.— A  person  who  has  been  exposed  to  the  infection  must  be  kept 
under  observation  for  23  days  ;  and,  as  the  disease  in  very  infectious  in  its 
earliest  stage,  it  is  desirable  to  isolate  on  the  least  suspicion  of  catarrh  or 
malaise. 

Scarlet  Fever. 

Incubation  Period. — The  period  is,  as  a  rule,  more  than  24  hours  and  less  than 
72  hours.     It  has  not  been  shown  ever  to  exceed  7  days. 

Infectious  Period. — A  patient  is  infectious  from  the  onset  of  the  earliest 
symptoms,  and  remains  so  until  long  after  convalescence  is  established.  A 
second  desquamation  may  be  infectious. 

Isolation. — Isolation,  to  be  effectual,  must  be  commenced  at  the  onset  of  the 
disease,  and  continued  for  seven  or  eight  weeks,  or  until  all  desquamation  has 
ceased.  As  the  infection  is  easily  preserved  in  fomites,  disinfection  should  be 
practised  with  great  care,  and  by  the  most  efficient  methods. 

Quarantine. — A  person  who  has  been  exposed  to  a  source  of  infection  should 
be  kept  in  quarantine  for  7  clear  days.  If  at  the  end  of  that  time  there  is  no 
elevation  of  temperature  and  no  indication  of  sore-throat  he  may  be  pronounced 
to  have  escaped  infection. 

Unrecognised  Cases. — The  symptoms  of  scarlet  fever  may  be  very  anomalous,  or 
very  little  marked,  and,  especially  in  the  adult,  may  consist  only  of  sore-throat. 
The  infection  is  often  spread  by  such  cases. 

Surgical  Scarlet  Fever. — The  production  of  a  traumatism,  surgical  or  other,  may 
determine  the  onset  of  scarlet  fever  in  a  person  who  has  been  exposed  to  infec- 
tion, but  who,  previous  to  the  traumatism,  appears  to  have  resisted  the  infection. 
It  is,  therefore,  unadvisable  to  perform  any  operation  which  can  be  deferred  upon 
a  patient  who  has  recently  been  in  an  infected  house  or  ward. 


Influenza. 

Incubation  Period. — The  usual  period  is  3  or  4  days  ;  but  it  may  be  as  long- 
as  5  days,  or  as  short  as  1  day  or  a  few  hours  less. 

Infectious  Period. — A  patient  is  infectious  from  the  onset  of  symptoms  until 
convalescence  has  been  sufficiently  established  to  enable  him  to  return  to  his 
ordinary  avocations. 

Diphtheria. 

Incubation  Period. — The  period  is  usually  2  days,  and  seldom  exceeds  4  days. 
Seven  days  is  the  longest  period  for  which  there  is  trustworthy  evidence. 

Infectious  Period. — A  patient  begins  to  be  infectious  in  the  incubative  stage, 
and  no  term  can  be  certainly  assigned  to  the  subsequent  duration  of  infection 
as  long  as  any  unhealthy  condition  of  throat  endures.  The  danger  certainly 
persists  for  one  or  two  months.  The  infection  can  be  retained  and  conveyed  by 
fomites. 

Quarantine. — Seven  clear  days  is  probably  sufficient,  if  at  the  end  of  that  time 
the  person  who  has  been  exposed  is  subjected  to  careful  medical  examination. 

Unrecognised  Cases. — The  infection  of  diphtheria  may  be  conveyed  by  cases  so 
mild  that  they  never  come  under  medical  treatment,  or  so  anomalous  that  their 
true  nature  is  not  recognised.     In  schools,  and  other  places  where  large  numbers 


APPENDIX    TO    SECTION    III.  226c 

of  susceptible  persons  are  gathered  together,  all  cases  of  sore-throat  ought  to 
be  isolated  as  though  they  were  diphtheria,  at  least  during  periods  of  epidemic 
prevalence. 

Enteric  Fever. 

Incubation  Period. — The  period  varies  very  much,  and  is  probably  in  large 
measure  determined  by  the  "  dose"  of  the  virus  received.  In  children  who  have 
drunk  freely  of  infected  milk  it  may  be  as  short  as  7  or  8  days  or  even  less.  The 
usual  period  is  12  or  14  days.     In  rare  cases  it  may  be  as  long  as  23  days. 

Infectious  Period. — Infection  lasts  from  the  onset  of  the  illness  until  convales- 
cence has  been  established  for  at  least  a  fortnight.  Infection  can  be  retained  in 
fomites  for  two  months  at  least. 

Mumps. 

Incubation  Period. — The  prodromal  stage  of  mumps  is  of  very  uncertain  dura- 
tion, and  frequently  passes  unperceived.  The  interval  between  exposure  and  the 
onset  of  parotitis  is  most  often  three  weeks,  a  day  more  or  a  day  or  two  less.  It 
may  be  as  long  as  25  days,  or  as  short  as  14. 

Infectious  Period. — The  prodromal  period  of  mumps  may  certainly  last  as 
long  as  4  days;  and  during  the  whole  of  this  period  the  patient  is  infectious, 
though  he  may  make  no  complaint  of  illness.  Infection  diminishes  progressively 
from  the  onset  of  the  parotitis,  and  ceases  in  a  fortnight,  or  at  most  three  weeks. 

Quarantine. — It  appears  that  the  infection  of  mumps  is  not  easily  conveyed  for 
even  a  short  distance.  Separation  of  a  patient  in  a  single  room  in  a  house  con- 
taining many  susceptible  persons  may  be  effectual.  Quarantine  should  last 
25  days.  A  susceptible  person  first  seen  10  days  after  exposure  to  infection  may 
be  placed  in  quarantine  with  every  prospect  of  preventing  infection  ;  and  it  is 
worth  while  to  resort  to  quarantine  if  exposure  has  taken  place  even  three  weeks 
earlier. 

[P.S. — Regarding  whooping-cough,  the  facts  submitted  to  the  Committee  were 
not  sufficiently  definite  or  numerous  to  afford  material  for  any  useful  conclusions. 
— H.  B.  D.] 


SECTION  IV. 

DISORDERS  OF  THE  NERVOUS  SYSTEM. 


SECTION  IV.— DISORDERS  OF  THE  NERVOUS 
SYSTEM. 

Disordered  nerve-function  forms  a  highly  important  part  of  the 
maladies  of  childhood,  and  most  of  the  affections  of  this  kind  which 
may  be  regarded  as  special  to  our  subject  are  largely  referable  to  the 
double  fact  of  the  higher  cerebral  centres  in  early  life  being  imperfectly 
developed  and  at  the  same  time  rapidly  developing. 

This  is  evidenced  not  only  by  inference  from  functions  but  also  by 
examination  of  the  new-born  child's  cerebral  cortex  which,  both  macro- 
scopically  and  microscopically,  is  of  far  less  structural  complexity  than  in 
the  adult.  Co-ordination  exists  but  in  its  lower  grades,  instability  of 
the  nervous  mechanism  is  conspicuous,  and  it  is  verily  out  of  disorder 
that  nervous  order  gradually  comes  into  being.  Hence  the  pre-eminent 
helplessness  of  the  infant  and  the  abounding  tyranny  of  its  environment. 
The  distinctively  human  qualities  of  the  individual  are  thus  late  in 
development,  even  as  was  man  himself  in  the  biological  series ;  and  the 
inchoate  organism  of  the  child  must  run  the  gauntlet  of  innumerable 
untoward  surroundings,  dependent  upon  others  for  the  higher  nerve- 
control  in  all  its  aspects.  We  may  thus  expect  to  find,  among  the 
nervous  disorders  of  infancy  and  childhood,  instances  of  arrest  and  of 
vices  of  development ;  multiform  aberrations  from  the  normal,  both 
temporary  and  permanent ;  and  many  evidences  of  falls  by  the  way 
during  the  progress  from  instability  to  co-ordinated  perfection  of  nervous 
function.  I  cannot  here  enlarge  as  I  would  on  this  point ;  but  content 
myself  with  remarking  that,  when  we  consider  the  double  function  of 
the  nervous  system  in  regulating  the  whole  individual  organism  and 
in  bringing  it  into  relation  with  the  external  world,  we  cannot  but 
recognise  that  this  formula  of  imperfect  nerve-control  may  be  applicable 
to  many  other  disorders  of  childhood  than  those  which  are  technically 
styled  "nervous."  It  may  at  least  be  said  that,  wherever  the  hypothesis 
of  a  nervous  origin  for  a  complex  of  morbid  symptoms  may  be  rationally 
applied,  it  has  mostly  a  double  force  when  the  matter  in  question  is 
disease  in  early  life. 

The  field,  however,  of  what  for  practical  purposes  are  known  as  diseases 
of  the  nervous  system,  is  less  wide  in  infancy  and  childhood  than  in  later 


230  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

life ;  for  with  many  affections  whose  predominant  symptoms  give  them  a 
place  in  this  category  we  have  little  or  nothing  to  do.  Such  for  instance 
are  numerous  diseases  of  the  adult,  due  to  degeneration  and  marked 
changes  in  tissue  either  within  or  without  the  nervous  structures,  and 
causing  symptoms  of  functional  failure  of  the  brain  or  spinal  cord. 

It  is  especially,  as  we  have  seen,  in  connection  with  the  brain  in 
childhood  that  nerve-affection  manifests  itself,  and  under  this  heading 
both  mental  and  physical  disorders  should  be  considered.  The  patho- 
logical part  played  by  the  spinal  cord  and  the  peripheral  nerves  is 
much  less  in  childhood  than  in  later  life.  I  shall,  however,  treat  of 
the  several  nervous  disorders  of  childhood  neither  in  anatomical  nor 
setiological  order,  for  no  classification  of  this  kind  can  be  practically 
useful,  involving,  as  it  does,  numerous  cross  divisions ;  but  shall  rather 
use  the  method  of  simple  enumeration  under  the  best  known  clinical 
titles,  whether  such  titles  be  taken  from  structural  change  or  from 
predominant  symptoms. 

I  have  been  forced,  by  reason  of  want  of  space,  to  forego  the  discussion 
of  mental  disorders  proper. 


CHAPTER  I. 

SPASMODIC    DISORDERS. 

The  affections  of  children  which  are  especially  marked  by  spasm,  with 
the  exception  of  those  occurring  in  association  with  prominent  paralysis 
and  hereafter  to  be  noticed,  may  be  clinically  grouped  under  the  fol- 
lowing headings  of  Infantile  Convulsions  and  Tetany,  Epilepsy,  and 
Localised  Spasms. 

Infantile  Convulsions. 

Convulsions  may  be  described  as  paroxysmal  attacks  of  involuntary 
muscular  contractions,  generally  accompanied  by  insensibility.  In  a 
slight  degree  the  convulsive  tendency  is  inherent  in  infancy,  by  reason 
of  the  cortical  incompleteness  already  mentioned ;  and  is  evidenced  by 
the  spasmodic  twitching  of  limbs  and  sudden  breathlessness  often  ob- 
served in  cases  where  neither  typical  convulsions  occur  nor  further 
neuroses  follow.  This  condition  I  have  seen  arise  in  healthy  young 
babies  who  from  some  cause  or  other,  as,  for  instance,  artificial  feeding, 
have  temporarily  failed  in  nutrition,  but  completely  disappear  when 
flesh  is  regained  by  appropriate  treatment.  Many  intermediate  grades 
may  exist   between    this   quasi-physiological  spasm  and   the    ordinary 


SPASMODIC    DISORDERS.  23  I 

convulsion  which  must  be  recognised  as  pathological.  There  is,  moreover, 
no  purely  symptomatic  distinction  between  infantile  convulsions  and 
epilepsy.  The  typical  and  fully -developed  attacks  of  both  are  identical 
in  appearance,  and  epilepsy  appears  in  various  guises.  The  differentiation 
of  the  epileptic  convulsion  in  all  its  aspects  depends,  as  we  shall  presently 
see,  on  other  considerations  than  the  character  of  the  actual  fit. 

Infantile  convulsions  may  be  general  or  partial  or  strictly  unilateral  in 
distribution.  The  trunk  is  usually  involved  in  the  spasm  as  well  as  the 
limbs.  It  may  be  said  that  severe  general  convulsions  in  early  infancy 
differ  from  those  in  later  life  in  that  they  most  often  lack  the  orderly 
march  of  the  spasm  from  the  smaller  and  more  specialised  muscles 
downwards  to  those  of  the  trunk.  Yet  we  may  not  seldom  observe  the 
fingers  and  thumb  of  one  hand  twitching  almost  simultaneously  with  the 
twisting  of  the  mouth  and  turning  of  the  eyes,  which  are  so  frequently  the 
first  observed  indications  of  the  coming  fit.  In  the  height  of  the  attack 
the  breathing  is  shallow  and  often  arrested,  the  face  blue,  the  saliva 
may  be  frothed  by  the  maxillary  movements,  and  there  is  frequently 
passage  of  urine  and  faeces.  The  separate  attacks  last  but  a  few  minutes  ; 
but  they  may  be  repeated  in  extremely  rapid  succession  for  even 
days  at  a  time,  the  intervals  being  often  occupied  by  varying  grades 
of  apathy  or  by  deep  coma.  It  is  in  cases  of  this  kind  that  there  is 
imminent  risk  of  death  through  engorgement  of  the  brain  and  lungs. 
In  but  few  instances  does  a  single  marked  convulsion  occur,  but  in 
many  there  are  long  intervals  between  the  fits.  General  convulsions, 
whether  slight  or  severe,  are  the  rule  in  infancy.  Unilateral  spasm, 
however,  is  often  noticed,  but  certainly  has  not  the  same  significance 
of  organic  mischief  in  the  brain  as  in  adult  life,  unless  it  be  frequently 
repeated  or  accompanied  by  lasting  hemiplegia.  Even  recurrent  uni- 
lateral convulsions  I  have  seen,  both  in  cases  which  recovered  without 
any  drawback  and  in  others  which  died  and  showed  no  cerebral  lesion  ; 
but  here,  when  making  our  diagnosis  and  forecast,  we  must  always  think 
of  the  probability  of  a  lesion  such  as  tubercle  or  other  growth,  or  of 
vascular  mischief  on  the  side  of  the  brain  opposite  to  the  spasms. 

Laryngismus  is  a  very  frequent  phenomenon  in  connexion  with  general 
convulsions,  especially  in  rickety  children;  it  may  indeed,  when  marked, 
be  regarded  as  almost  exclusively  an  indication  of  rickets.  Of  this,  how- 
ever, I  speak  more  in  detail  under  another  heading. 

Very  often  the  attack  is,  like  epilepsy,  represented  by  nothing  which 
can  be  called  a  convulsion,  there  being  but  a  temporary  loss  of  conscious- 
ness, a  catching  of  the  breath,  a  sudden  waking  with  a  start,  or  a  falling 
forwards  of  the  head  and  stertorous  breathing  for  a  few  seconds. 

Regarding  the  aetiology  of  infantile  convulsions  I  shall  say  nothing 
but  what  is  special  to  the  subject  and  confine  myself  to  what  appear 


2  32  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

to  be  the  clinical  conditions,  both  predisposing  and  exciting,  out  of 
which  they  arise ;  referring  the  reader  for  the  general  pathogeny  of 
spasm,  including  of  course  epilepsy,  to  larger  works,  and  especially  to  the 
teaching  of  Dr.  Hughlings  Jackson.  An  admirable  article  by  Dr.  James 
Anderson,  clearly  stating  Dr.  Jackson's  views,  is  to  be  found  in  Tuke's 
Dictionary  of  Psychological  Medicine. 

Nervous  heredity  of  many  kinds  and  rickets  are  the  two  conditions 
which,  one  or  both,  underlie  an  enormous  majority  of  all  cases  of 
convulsions  in  childhood,  whatever  the  immediately  exciting  or  reflex 
causes  of  the  attacks  may  appear  to  be.  This  rule  applies,  I  think, 
to  most  fits  which  usher  in  acute  disease,  as  well  as  to  those  which 
strictly  concur  with  difficult  dentition,  with  markedly  deranged  diges- 
tion, or  with  definite  psychical  disturbances  such  as  fright.  My  colleague 
Dr.  Coutts  has  shown  that  the  occurrence  of  fits  at  the  onset  of  acute 
disease  is  much  rarer  than  is  usually  believed ;  and  I  entirely  agree  with 
his  contention  that  most  of  the  cases  even  thus  occurring  are  connected 
with  either  rickets  or.  pronounced  neurotic  heredity.  But  nevertheless 
I  would  urge  the  practical  caution  that,  when  fits  take  place  for  the  first 
time,  especially  after  the  earliest  infancy,  and  there  is  any  rise  of  tem- 
perature, we  should  never  forget  the  possible  sequence  of  pneumonia  or 
other  acute  febrile  disease,  however  good  the  personal  and  family  history 
of  the  case  may  be. 

Among  organic  diseases  of  the  brain,  and  other  affections  which  may 
occasion  the  nervous  discharge  resulting  in  convulsion,  we  must  bear  in 
mind  all  kinds  of  meningitis,  and  especially  the  tubercular  form,  in  which 
convulsion  may  occur  at  any  period  and  is  not  seldom  the  first  observed 
symptom  ;  cerebral  thrombosis  and  embolism  ;  injuries  to  the  head  ;  otitis 
media ;  tumours ;  and  sometimes  haemorrhages,  both  meningeal  and 
cerebral.  Convulsions  also  frequently  take  place  at  the  outset  of  chronic 
hydrocephalus  ;  in  wasting  diseases  involving,  perhaps,  arterial  anaemia  of 
the  brain  ;  with  venous  hyperaemia  of  the  brain  as  instanced  in  pertussis  ; 
and  sometimes,  seemingly,  in  direct  association  with  high  temperature. 
I  enumerate  these  conditions  as  concomitant,  but  not  necessarily  causal. 
In  exhausting  diseases,  such  as  diarrhoea  and  vomiting  and  many  others, 
convulsion  is  the  immediate  herald  of  death,  attended,  not  infrequently, 
by  a  considerable  rise  of  temperature. 

It  must  not  be  forgotten  that  general  convulsions  not  seldom  occur  in 
connexion  with  coarse  disease  limited  entirely  to  one  side  of  the  brain ; 
that  they  are  antecedents  of  many  cases  of  infantile  hemiplegia  and 
sometimes  of  aphasia  alone  in  varying  degree  according  to  the  stage  of 
the  child's  development;  and  that  they  may  be  associated  with  renal 
disease.  We  must  therefore  search  with  all  care  for  concomitant  symp- 
toms of  brain  or  other  affection,   examine  the  urine  for  albumen,  and 


SPASMODIC  DISORDERS.  233 

exercise  due  caution  before  pronouncing  upon  the  possible  nature  and 
import  of  any  given  case  of  convulsions. 

When  one-sided  convulsions  occur  without  local  disease  of  brain  they 
are  not  constant  in  seat,  but  often  shift  from  one  side  to  the  other. 
Local  paralysis,  and  marked  inequality  of  pupils,  following  on  convul- 
sions, point  strongly  to  the  probability  of  brain-disease.  Protracted 
strabismus  is  also  suspicious,  although  this  symptom  may  last  for  long 
after  convulsions,  with  no  other  indication  of  organic  mischief.  Above 
all,  localised  convulsions  of  recurrent  character  and  fixed  seat,  and  appa- 
rently unaccompanied  by  loss  of  consciousness,  indicate  with  the  greatest 
probability  the  existence  of  organic  disease  of  the  cerebral  cortex. 

Besides  those  sequelae  of  repeated  convulsive  attacks  which  have 
already  been  glanced  at,  more  or  less  permanent  mental  deficiency  may 
be  observed,  and  other  marked  neuroses  may  ultimately  follow.  Accord- 
ing to  Dr.  Coutts,  who  has  studied  the  question  of  the  sequelae  of  infantile 
convulsions,  there  is  much  evidence  that  a  considerable  proportion  of  the 
subjects  of  this  affection  in  its  ordinary  form  suffer  in  later  years  from 
definite  nervous  trouble.  He  found l  that  40  out  of  85  subjects  of  in- 
fantile convulsions  were  in  later  life  victims  of  epilepsy,  somnambulism, 
insanity,  chorea  or  migraine  ;  and  that  of  the  remaining  45  most  were 
either  eccentric  and  irritable  or  below  their  brothers  and  sisters  in 
intelligence.  Although  it  seems  necessary  to  discount  these  figures  to 
some  extent,  owing  to  the  method  of  inquiry  which  in  many  of  the  older 
cases  must  have  proceeded  backwards  from  the  fact  of  present  neurosis 
to  the  history  of  past  convidsion,  a  perusal  of  Dr.  Coutts'  arguments 
and  further  illustrations  will  afford  us  substantial  reasons  for  regarding 
infantile  convulsions  as  a  very  probable  danger-signal  to  the  future 
nervous  health  of  their  subjects. 

The  later  the  period  at  which  the  convulsions  of  early  childhood  set 
in,  the  more  probable  is  their  epileptic  nature ;  and  in  many  cases  there 
seems  to  be  no  breach  of  continuity  between  the  fits  of  infancy  and  the 
epilepsy  of  a  lifetime.  It  is  known  that  the  origin  of  many  cases  of 
epilepsy  is  traceable  to  the  first  year,  and  that  a  large  majority  have  a 
markedly  bad  neurotic  heredity. 

The  most  favourable  elements  of  prognosis  in  the  convulsions  of 
infancy  are  the  absence  of  organic  brain-disease  and  of  discoverable 
neurotic  heredity ;  infrequency  of  attacks  ;  and  the  presence  of  any 
strongly  presumable  excitant  of  reflex  action,  such  as  marked  alimentary 
disturbance  or  shock  in  close  association  with  the  fits  in  question,  and 
thus  perhaps  evidencing  external  stress  sufficient  to  impress  even  a  fairly 
stable  specimen  of  the  infantile  nervous  system.  I  may  remark  here, 
however,  that  I  believe  the  cases  to  be  rare  where  fits  can  be  referred 
1  See  art.  "  Convulsions  in  early  childhood,"  Medical  Magazine,  Aug.  1892,  London. 


234  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

to  parasitic  worms  as  an  immediate  excitant.  I  have  certainly  met 
with  a  case  or  two  where  fits  occurred  just  before  the  vomiting  of  a 
"  lumbricus,"  but  I  have  no  knowledge  of  convulsions  being  occasioned 
by  oxyuris  or  taenia.  It  is  but  seldom  that  I  have  been  forced  to  re- 
cognise alimentary  disorder  as  a  determining  cause,  except  in  cases  of 
markedly  rickety  or  neurotic  children.  No  diagnostic  importance  can 
be  granted  to  the  contention  of  some  that  in  young  infants  who  are 
well  nourished  the  fits  are  reflex,  while  in  those  who  are  wasted  they 
are  due  to  some  intra-cranial  lesion.  Experience  alone,  not  to  mention 
the  probable  pathology  of  convulsion,  falsifies  this  misleading  statement 
at  every  turn.  Eepeated  convulsions,  however,  in  wasted  and  apathetic 
infants  are  always  of  grave  prognostic  import,  being  often,  as  we  have 
seen,  a  mode  of  dying. 

Post-mortem  examination  in  cases  which  have  suffered  from  convul- 
sions usually  reveals  nothing.  Pronounced  venous  congestion  of  the  brain 
or  small  extravasations  are,  however,  found  in  many  cases  of  repeated 
convulsions  immediately  preceding  or  coincident  Avith  death.  There  is- 
but  little  evidence  of  localised  lesion  of  brain  resulting  from  convulsions  ; 
nor,  in  consequence,  can  we  refer  the  permanent  epileptic  condition,  which 
doubtless  often  follows  on  fits  in  children,  to  such  an  hypothetical  cause. 

The  treatment  of  convulsions  is  a  simpler  matter  than  the  acknow- 
ledged difficulty  of  aetiological  diagnosis  would  suggest.  Practically 
we  have,  in  severe  and  repeated  cases,  to  do  what  is  possible  towards 
checking  the  convulsions,  seeing  that  they  are  not  only  alarming  but 
may  also  be  sometimes  fatally  injurious  by  causing  engorgement  of 
brain  and  lungs.  For  this  purpose  inhalation  of  chloroform,  cautiously 
administered,  is,  I  think,  one  of  the  best  remedies,  on  which,  in  my 
experience,  good  results  have  sometimes  followed.  It  should  not,  how- 
ever, be  used  when  there  are  already  signs  of  lung-  or  heart-failure  or 
serious  collapse.  The  cyanosis  produced  by  the  fit  is  in  my  opinion, 
as  in  Henoch's,  no  contra-indication  to  the  use  of  chloroform.  Another 
decidedly  useful  method  is  the  rectal  injection  of  a  few  grains  of  chloral 
hydrate,  according  to  age,  with  or  without  bromide  of  potassium.  Of 
this  treatment  Mr.  J.  Scott  Battams  speaks  highly.  Administration 
of  opium  or,  when  swallowing  is  impossible,  subcutaneous  injection 
of  morphia  is  often  very  useful  in  preventing  the  recurrence  of  fits. 
One  thirtieth  to  one  twenty-fourth  of  a  grain  may  be  given  to  a  child 
of  a  year  old.  In  prolonged  cases  the  bromides  are  very  serviceable, 
and  I  have  found,  both  in  children  and  adults,  that  the  ammonium  salt 
is  as  efficient  as  that  of  potassium.  I  also  believe  that  for  continuous 
use  it  is  far  preferable.  Chloral  in  small  doses  and  belladonna  may  be 
tried  in  chronic  cases.  Nitrite  of  amyl  inhalations  may  be  advantageously 
used  during  the  attack,  according  to  some  authorities  ;  but  in  my  own 


SPASMODIC  DISORDERS.  235 

small  experience  of  this  remedy  it  has  been  ineffectual.  I  always  order 
the  hot  bath,  partly  from  convention,  and  partly  because  it  sometimes 
seems  to  do  good.  In  all  fits,  whether  severe  enough  to  indicate  such 
checks  as  above-mentioned  or  of  a  milder  character  and  less  frequent 
occurrence,  we  should  search  for  any  possible  excitant  and  endeavour  to 
remove  it,  however  doubtful  we  may  be  of  its  causal  role.  For  this  end 
emetics  and  purgatives  may  be  given  without  hesitation  and  sometimes 
with  success,  and  in  cases  where  there  is  obvious  swelling  and  redness 
about  the  gums  there  can  be  no  objection  to  free  lancing. 

Tetany. 

I  refer  to  this  affection  under  a  separate  heading  mainly  in  deference 
to  usage,  and  partly  because  the  symptoms  to  which  this  name  has  been 
given  are  said  to  be  quite  as  common  in  later  childhood  and  early  youth 
as  in  infancy.  In  my  own  experience  of  patients  of  all  ages  tetany 
has  been  mostly  seen  in  infants  and  quite  young  children.  It  is 
chiefly  marked  by  tonic  contractions  of  the  hands  and  feet  (carpo-pedal) ; 
the  thumbs  being  stiffly  bent  across  the  palms,  the  metacarpal  joints 
flexed,  and  the  fingers  extended.  The  soles  are  arched,  and  there  is 
generally  evidence  of  pain  with  the  occurrence  of  the  cramps  which 
may  last  for  long  with  intermissions  of  varying  duration.  There  may 
be  slight  twitchings  of  the  facial  and  other  muscles,  either  spontaneous 
or  produced  by  irritation  of  the  cutaneous  nerves  ;  but  the  clinical  picture 
generally  is  one  of  tonic,  not  clonic,  contraction.  In  infancy,  certainly, 
tetany  arises  in  the  same  serological  conditions  as  the  convulsions  of 
which  I  have  spoken  above,  being  notably  connected  with  rickets  and 
exhausting  diseases,  especially  intestinal ;  and  it  not  seldom  exists  in  the 
intervals  of  clonic  attacks.  In  some  cases  the  wrists  and  elbows  are 
tonically  flexed,  and  the  ankle-  and  knee-joints  may  be  rigid  in  flexion 
or  extension.  This  state  may  last  for  days  or  weeks,  and  occasionally 
there  is  oedema  on  the  dorsal  surface  of  the  hands  and  feet.  I  have  seen 
one  very  typical  case  of  extensive  tetany,  involving  the  large  as  well  as 
the  small  joints,  with  redness  and  oedema  of  feet,  where  the  child,  aged 
18  months,  remaining  tetanised  and  perfectly  conscious  for  nearly  a 
fortnight,  was  thereafter  seized  with  violent  clonic  convulsions  which 
were  nearly  fatal.  It  soon  made  a  good  recovery.  Previous  to  this 
attack  the  child  had  been  perfectly  well,  but  there  was  some  evidence 
of  rickets.  In  patients  beyond  infancy  what  may  be  called  the  purest 
examples  of  this  so-called  tetany  are  found,  quite  unaccompanied  at  any 
period  by  clonic  convulsions,  and  unmarked  by  loss  of  consciousness  or 
other  cerebral  symptoms.  There  is  sometimes  in  these  older  cases  more 
wide-spread  tonic  spasm  including  the  trunk  muscles  ;  and,  as  it  is  said 


236  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

and  as  I  have  seen  in  one  case,  contraction  of  the  muscles  of  the  jaw. 
Confusion  is  possible  here  between  tetany,  which  is  in  itself  harmless, 
always  of  good  prognosis  and,  as  we  have  seen,  closely  allied  to  other 
conditions  of  functional  spasm,  and  true  tetanus.  Many  reported  cases 
of  so-called  chronic  idiopathic  tetanus  have  been  doubtless  instances  of 
tetany.  Tetany  has  been  observed  by  some  as  a  kind  of  nervous 
epidemic  among  girls,  and,  as  such,  is  doubtless  closely  allied  to  the 
various  spasms  of  hysteria  and  hystero-epilepsy.  The  affection  is  said 
to  be  often  connected  with  taking  cold.  For  clinical  purposes  I  think 
it  is  better  to  separate,  as  Henoch  does,  these  tonic  contractions,  which 
attack  infants  in  close  connexion  with  convulsions,  from  the  more 
unmixed  forms  which  occur  in  later  age ;  but  there  is  no  hard  and  fast 
line  of  division  either  in  appearance  or  aetiology,  and  the  term  tetany 
is  now  generally  used  in  the  most  comprehensive  sense. 

In  infancy  the  treatment,  both  symptomatic  and  general,  is  similar  to 
that  of  convulsions.  Calabar  bean  has  been  recommended  in  doses 
varying  from  -^  to  \  grain,  but  the  duration  of  the  attacks  so  treated, 
including  one  case  of  my  own,  in  no  way  points  to  any  curative  action. 
In  older  cases  general  treatment  for  neurotic  disorder,  as  alluded  to 
under  the  heading  of  hysteria,  is  the  best  line  to  follow. 

Epilepsy. 

Under  this  term  I  include  the  recurrent  attacks  of  impairment  or  loss 
of  consciousness,  often  attended  by  convulsions  of  varying  degree  and 
distribution,  which  are  usually  known  as  "idiopathic"  epilepsy;  excluding 
the  unilateral  or  strictly  localised  spasms,  known  as  Jacksonian  epilepsy, 
which  are  mostly  unattended,  at  least  at  the  outset,  by  loss  of  conscious- 
ness and  are  connected  with  localised  disease  in  the  cerebral  cortex. 
A  not  uncommon  form  of  convulsions,  however,  sequent  on  hemiplegia 
in  infants  and  young  children,  where  the  spasms,  though  most  often 
confined  to  the  paralysed  side,  are  frequently  general  and  in  all  respects 
indistinguishable  from  idiopathic  epilepsy,  must  be  dealt  with  in  this 
context. 

Epilepsy  as  above  indicated  shows  itself  in  childhood,  as  in  adults,  in 
various  forms,  and  in  all  grades  from  short  affections  of  consciousness 
or  "  petit  mal "  to  the  well-known  convulsive  attack  or  "  grand  mal." 
It  is  pre-eminently  a  disease  of  early  life ;  three-fourths  of  all  cases 
beginning  before  twenty,  and  more  than  one-fourth  before  ten  years 
of  age.  Its  onset  is  most  frequent  in  the  first  year,  and  at  or  about 
the  period  of  puberty. 

Owing  to  the  incomplete  development  of  the  infantile  brain  and  the 
imperfect  powers  of  expression  in  early  childhood  we  often  meet  with 


SPASMODIC  DISORDERS.  237 

less  clearly  defined  order  of  spasm  than  in  later  years;  and  the  "aurae," 
though  occurring  in  many  varieties,  both  physical  and  psychical,  are  less 
easily  discovered  and  described.  In  children  beyond  early  infancy  the 
attacks  rapidly  approximate  to  those  of  later  life,  neither  the  spasms 
nor  the  aura?  needing  special  description.  I  have  seen  cases  illustrating 
many  of  the  auras  referred  to  in  monographs,  the  multiform  epigastric 
sensations  being  the  most  frequent. 

Two  considerable  difficulties  meet  us  respecting  the  diagnosis  of 
epilepsy  in  infancy  and  later  childhood  respectively.  On  the  one  hand 
infantile  convulsions  are  often  indistinguishable  from  those  which  by 
the  sequel  are  proved  to  be  chronic  epilepsy ;  and  on  the  other  both  the 
mental  and  physical  phenomena  of  the  condition  known  as  hysteria 
may  closely  resemble  epilepsy,  and,  indeed,  both  alternate  with  and 
sometimes  obscure  undoubted  epileptic  seizures.  The  questions  of  the 
diagnosis  of  epilepsy  and  the  prognosis  of  convulsions  in  infancy  are 
practically  the  same,  and,  with  the  exception  of  most  cases  connected 
with  organic  brain-disease,  are  very  often  insoluble  at  the  time  when  their 
importance  is  greatest.  Frequency  of  attacks,  absence  of  discoverable 
excitants,  the  exclusion  of  rickets,  marked  neurotic  and  epileptic  heredity 
and,  perhaps,  good  general  health  may  be,  more  or  less,  comparatively 
indicative  of  epilepsy ;  but  none  of  these  points  can  be  absolutely  relied 
on  in  the  diagnosis  of  any  given  case.  If  frequent  losses  of  conscious- 
ness without  convulsions  can  be  discovered  by  observations  of  altered 
facial  expression,  of  sudden  quietness,  or  of  spells  of  noisy  breathing, 
the  suspicion  of  epilepsy  is  thereby  strengthened.  I  cannot  agree  with 
the  view  that  the  actual  presence  of  rickets  enables  us  to  make  an 
absolute  distinction  between  ordinary  convulsions  and  epilepsy ;  for, 
although  infantile  convulsions  frequently  cease  with  receding  rickets, 
they  are  often  persistent ;  and  an  hereditary  tendency  to  epdepsy  and 
other  neuroses  is  especially  marked  in  many  cases  of  repeated  convul- 
sions with  rickets.  It  is,  moreover,  frequently  found  that  epilepsy, 
apparently  beginning  in  late  childhood  or  adult  life,  has  been  preceded 
by  convulsions  in  infancy.  This  takes  place,  according  to  Gowers, 
Hughes  Bennett,  and  other  authorities,  in  from  7  to  15  per  cent,  of  all 
cases  of  epdepsy,  and  is  probably  still  more  frequent;  for  infantile 
convulsions  are  very  often  overlooked  or  forgotten.  In  most  cases, 
then,  of  recurrent  convulsions  in  children  under  two  years  old,  lapse  of 
time  alone,  as  we  have  seen,  will  be  a  useful  guide  to  prognosis.  After 
this  age  the  diagnosis  of  epilepsy  rests  on  a  firmer  basis. 

Our  second  difficulty  meets  us  in  cases  of  later  date,  which  are  often 
marked  by  strange  alterations  of  conduct  and  a  multiform  hysterical 
display.  The  epileptic  seizures,  which  are  ready  present  but  perhaps 
detectable   only  by  careful   observation,  especially  when  of   the  kind 


238  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

known  as  "  petit  nial,"  are  often  obscured  by  or  alternate  with  convulsive 
attacks,  which,  however  violent,  are  marked  by  movements  akin  to  volun- 
tary, the  eyes  being  closed  and  high  grades  of  consciousness  shown  by 
various  signs.  There  may  also  be  anaesthesia  and  other  phenomena  of 
deep  hysteria,  which  are  demonstrably  beyond  the  control  of  the  will. 
I  shall  further  treat  of  such  symptoms  under  the  head  of  hysteria, 
merely  alluding  to  them  here  to  emphasise  the  frequently  close  alliance 
between  epilepsy  and  hysteria,  and  the  prominently  psychical  elements  of 
epilepsy  known  as  epileptic  "  vertigo  "  and  "  mania,"  marked  instances 
of  which  occur  even  in  young  children.  The  lesson  to  be  learned  is  that, 
masked  by  so-called  hystero-epilepsy  and  hysteria  and  sometimes  by 
acts  of  apparent  imposture  and  by  general  depravity,  true  epilepsy  may 
not  seldom  be  met  with  in  children  as  well  as  in  adults. 

The  clinical  aetiology  of  epilepsy  in  childhood,  apart  from  such  cases 
as  are  connected  with  rickets,  involves  no  special  consideration.  Neurotic 
heredity  is  manifest  in  many  cases,  as  shown  by  the  history  of  epilepsy 
itself,  chorea,  insanity,  migraine  and  other  disorders  in  near  relatives, 
and  some  of  these  affections  may  concur  in  the  individual  patient.  It  is 
unnecessary  to  discuss  the  question  of  the  exact  connexion  between 
infantile  convulsions  and  epilepsy  ;  but  it  may  be  said  that,  although  the 
chronic  condition  may  be  the  direct  result  of  this  repetition  of  impres- 
sions left  by  the  early  attacks,  the  very  repetition  in  question  is  a  strong 
indication  of  special  nervous  instability. 

Epilepsy  often  marks  congenital  idiocy  in  its  various  grades,  but  may 
make  its  appearance  at  different  periods,  one  of  my  cases,  a  micro- 
cephalic, having  had  his  first  fit  at  five  years  old.  In  several  others 
there  was  marked  and  rapid  mental  impairment  after  the  epilepsy  had 
declared  itself ;  and  it  is  a  general  rule  that  the  more  frequent  the  fits, 
especially  when  of  both  forms,  the  more  decided  and  constant  is  the 
mental  disturbance.  I  had  once  a  mentally  deficient  patient  of  seven 
years  old  with  marked  epilepsy  continuous  with  infantile  convulsions, 
all  of  whose  six  brothers  and  sisters  had  suffered  from  convulsions  which, 
in  most,  had  ceased  in  infancy. 

Exciting  causes  of  the  first  fit  in  children  over  four  or  five  years  old, 
whether  or  not  they  have  had  convulsions  in  early  infancy,  can  sometimes 
be  made  out  with  great  probability.  A  boy  who  had  had  a  few  con- 
vulsions in  infancy  had  his  first  subsequent  fit,  at  the  age  of  eight,  imme- 
diately after  breaking  his  arm.  I  saw  him  six  weeks  afterwards,  when 
his  attacks  were  typical  and  frequent,  with  intervals  of  tetany,  mania, 
and  filthy  habits.  He  gradually  improved  with  large  doses  of  bromide, 
but  remained  very  stupid.  Another  boy,  aged  9,  previously  healthy, 
had  suffered  for  two  years  from  epileptic  convulsions  beginning  imme- 
diately after  he  had  been  nearly  drowned ;  and  I  could  mention  many 


SPASMODIC  DISORDERS.  239 

similar  instances  of  apparent  excitation  of  first  attacks.  Disturbance  of 
this  kind,  I  believe,  may  determine  epileptic  seizures  in  childhood  more 
readily  than  in  adults  ;  and  careful  hospital  treatment  even  without  drugs, 
or  a  similar  regime,  is  pre-eminently  likely  at  this  period  to  cause  a 
prolonged  remission  of  even  very  frequent  attacks. 

I  have  seen  several  cases  which  began  during  fever  or  acute  pulmonary 
attacks  or  in  early  convalescence  therefrom,  and  often  between  one  and 
two  years  old.  In  a  boy  of  six  years,  with  innumerable  fits  and  marked 
epileptic  heredity,  the  first  attack  was  at  three  years  of  age  on  recovery 
from  scarlet  fever.  Many  cases  start  just  after  a  fall  or  blow  on  the  head, 
and  I  think  that  at  all  ages  a  subordinately  causal  nexus  must  here  be 
recognised. 

There  is  a  frequent  connexion  between  hemiplegia  and  epilepsy  hi 
infancy  and  early  childhood,  apart  from  those  definitely  one-sided  fits 
due  to  localised  cortical  disease,  as,  for  instance,  tubercular  or  other 
tumours,  which  I  have  excluded  from  the  present  consideration  of 
epilepsy.  The  diagnosis  of  the  organic  cause  of  such  fits  rests  mainly 
on  their  frequent  recurrence  in  unvaryingly  unilateral  or  mono-spastic 
form,  unaccompanied  by  the  psychical  elements  of  epilepsy,  and  mostly 
attended  by  such  symptoms  of  cerebral  disease  as  headache,  vomiting  or 
localised  paralyses.  Almost  all  cases  of  infantile  hemiplegia  begin  with 
convulsions,  and  are  frequently  followed  by  permanently  recurrent  attacks, 
which  in  many  instances  are  general  as  regards  the  spasm  and  in  no  way 
distinguishable  from  ordinary  epilepsy.  There  is  good  reason,  as  we 
shall  presently  see  when  considering  hemiplegia,  for  attributing  the 
hemiplegia  in  many  of  these  cases  to  venous  thrombosis  in  the  cortex  or 
lower  cerebral  centres,  and  to  regard  the  convulsions  as  the  result  of 
brain  disturbance  consequent  on  the  lesion.  Most  of  these  cases  occur 
in  the  first  few  years  of  life ;  several  recover  partially,  and  some  com- 
pletely. When  the  spasms  are  exclusively  unilateral,  involving  the 
paralysed  side  only,  the  lesion  has  probably  been  considerable ;  but  in 
the  chronic  cases  with  general  convulsions,  which  especially  concern  us 
here,  the  original  lesion  has  to  a  great  extent  disappeared,  leaving  its 
effects  in  permanent  instability.  The  oldest  case  of  the  kind,  out  of 
many  that  I  have  seen  in  children,  took  place  at  ten  years  of  age.  In 
one  instance  of  well-marked  general  epilepsy,  in  a  girl  of  thirteen  years 
old,  the  fits  had  been  constant  since  the  first  year  when  a  severe  con- 
vulsion had  occurred,  lasting  twelve  hours,  and  followed  by  permanent 
paralysis  of  the  right  arm.  Many  of  my  cases  were  hemiplegia  of 
typical  distribution,  involving  arm,  leg,  tongue  and  lower  facial  region, 
and  thus  indicating  the  neighbourhood  of  the  internal  capsule  as  the 
seat  of  the  lesion.  In  some  of  the  right-sided  cases  there  was  also 
marked  aphasia. 


240  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

A  temporary  hemiplegia  or  comparative  paresis  of  one  side  is  often 
seen  in  children,  as  in  adults,  after  violent  or  repeated  epileptic  fits.  This 
is  to  be  regarded  as  due  to  exhaustion  of  the  nerve-centres.  It  is  recog- 
nised on  the  side  which  has  been  chiefly  or  alone  convulsed,  and  usually 
affects  the  limbs  without  the  face. 

Before  leaving  the  subject  of  the  symptoms  and  diagnosis  of  epilepsy 
in  childhood  I  must  emphasise  the  frequent  mistake  of  taking  attacks  of 
"petit  nial"  for  syncope.  This  diagnostic  error  is  often  made  in  the 
case  of  adults  as  well,  but  the  very  frequent  occurrence  of  epileptic 
attacks  without  convulsion  is  especially  overlooked  in  children.  I  have 
repeatedly  met  with  such  cases,  marked  by  temporary  loss  of  conscious- 
ness, with  or  without  staggering  or  falling,  and  many  of  them  subsequently 
developing  the  convulsive  form,  Avhich  have  been  called  fainting  fits  by 
both  medical  and  lay  observers.  Simple  syncope,  be  it  always  remem- 
bered, is  extremely  rare  in  childhood,  and  is  almost  confined  to  cases  of 
great  prostration  or  exhausting  disease,  and  to  conditions  where,  as  in 
enteric  fever  or  in  pronounced  anaemia,  there  may  be  temporary  or  chronic 
cardiac  dilatation.  It  is  moreover,  unlike  the  far  more  frequent  "  petit 
mal "  which  is  most  often  quite  unheralded  by  "  aura,"  preceded  by 
nausea,  or  sweating,  or  a  distressed  feeling  of  "  going  to  faint ; "  and  is 
generally  caused  by  exertion  or  excitement.  An  immense  majority  of 
so-called  fainting  fits  at  all  ages,  especially  when  recurrent  without 
recognisable  cause  and  attacking  otherwise  healthy  people,  are  without 
doubt  epileptic.  I  must  also  mention  night  terrors,  especially  when 
frequent  and  accompanied  by  hallucinations,  as  often  co-existent  with 
and  indicative  of  epilepsy ;  and  in  many  cases  habitual  somniloquence 
and  somnambulism  have  a  similar  association. 

The  prognosis  in  the  epilepsy  of  childhood  must  be  especially  guarded, 
considerably  fewer  cases  recovering,  according  to  Gowers  who  deals  -with 
large  numbers  of  cases  at  all  ages,  than  of  those  which  begin  in  later 
years ;  and  the  acknowledged  diagnostic  difficulty  as  regards  convulsions 
in  infancy  renders  a  really  useful  forecast  at  this  period  for  the  most 
part  impracticable.  Doubtless,  however,  a  certain  number  of  cases, 
apart  from  all  treatment,  tend  to  improve  or  recover  as  years  go  on, 
however  inveterate  they  may  have  appeared.  The  longer  the  disease 
has  lasted,  and,  generally  speaking,  the  more  frequent  the  attacks,  the 
worse  is  the  ultimate  prognosis  ;  but  I  know  of  no  good  criterion  to  apply 
to  any  individual  case.  Gowers  shows  that  hereditary  cases  recover  or 
are  arrested  far  more  often  than  those  without  such  a  history.  He  also 
gives  reason  to  believe  that  the  prognosis  is  worse  when  the  attacks  occur 
both  in  sleeping  and  waking  than  when  confined  to  either  of  these  states 
alone. 

The  best  result  we  can  look  for,  as  a  rule,  is  a  diminution  or  arrest  of 


SPASMODIC  DISORDERS.  24  I 

the  fits  under  treatment,  and  this  takes  place  in  varying  decrees  with  the 
use  of  the  bromides. 

As  regards  treatment,  the  epileptic  child  must  he  guarded  from  all 
demonstrable  or  suspected  exciting  causes  of  the  attacks,  and  sedulously 

nurtured  and  taught,  with  avoidance  of  all  mental  strain.  Plenty  of 
easily  digestible  food,  abundant  fresh  air  and  sunlight,  and  the  medicinal 
tonics,  are  all  indicated.  When  the  fits  are  as  frequent  as  one  or  more 
in  a  fortnight  I  tentatively  give  the  bromide  of  ammonium  or  potassium, 
persisting  with  the  administration  of  this  drug  in  proportion  to  the 
frequency  of  the  attacks.  But  when  the  intervals  are  longer  than  a  fort- 
night I  am  strongly  opposed  to  the  routine  prescription  of  the  bromides, 
and  especially  of  the  potassium  salt  which  is  so  frequently  given  on 
the  slightest  suspicion  of  an  epileptic  tendency.  It  may  be  possible 
that  cases  beginning  in  quite  early  life  with  frequent  convulsions  may 
be  checked  from  further  development  by  the  use  of  the  bromides,  such 
an  hypothesis  being  incapable  of  either  proof  or  disproof ;  and  it  is  un- 
questionable that  fits  can  be  lessened  in  frequency  or  kept  in  abeyance 
during  continuance  of  the  drug.  But  beyond  this  there  is  nothing 
certain  ;  and  I  have  no  doubt,  judging  from  carefully  observed  cases  both 
in  adults  and  children,  that,  notwithstanding  much  that  has  been  said 
on  the  other  side,  the  constant  use  of  the  bromides  is  eminently  depressing 
and  injurious  to  the  nervous  system  and  the  mind.  Such  evil  effects,  if 
not  of  very  long  standing,  are  doubtless  mostly  recovered  from  on  the 
discontinuance  of  the  drug ;  but  there  is  at  least  a  danger  of  setting  up  a 
permanent  listless  habit,  and  anorexia  or  dyspepsia  difficult  to  overcome. 

In  severe  and  inveterate  cases  other  drugs  may  be  tried,  but  few  will 
be  found  of  any  value.  I  have  frequently  tried  both  belladonna  and 
strychnia  with  at  the  best  but  very  doubtful  effect,  and  can  say  but 
little  in  favour  of  borax. 

In  cases  where  the  bromides  are  to  be  given  I  begin  with  the 
ammonium  salt,  as  less  depressing,  and  seldom  now  have  to  change  it  for 
that  of  potassium.  I  give  from  five  to  seven  grains  for  a  dose  to  children 
of  a  year  old,  and  often  up  to  twenty  or  thirty  after  the  age  of  10  or  12. 
I  cannot  call  to  mind  a  case  where  the  potassium  salt  has  succeeded  in 
checking  fits  where  the  other  has  failed,  though  there  have  been  many 
where  both  proved  nearly  useless.  In  all  cases  where  the  drug  seems  to 
be  doing  good,  it  should  be  stopped  for  a  while,  and  instantly  resumed  if 
the  fits  recur.  By  this  method  we  shall  soon  find  individual  indications 
for  continuance,  remission,  or  complete  omission  of  the  medicine.  In 
cases  -where  the  fits  always  return  on  omission  of  the  bromides  the  drug 
should  be  given  for  at  least  six  months  continuously,  even  when  the  fits 
have  altogether  ceased.  After  this  period  the  doses  may  be  diminished 
in  amount  and  frequency  during  another  six  months,  when  omission  may 

Q 


242  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

be  once  more  attempted.  I  have  often  tried  the  combination  of  arsenic 
with  bromides  in  those  frequent  cases  where  the  nodular  skin-eruption 
appears,  but  have  scarcely  ever  even  suspected  any  good  effect.  The 
inhalation  of  amyl  nitrite  is  apparently  successful  sometimes  in  preventing 
the  accustomed  convulsive  attack  from  following  on  the  aura ;  and  there 
is  some  evidence  to  show  that  nitro-glycerine  may  be  useful'  even  in  cases 
of  "petit  mal."  I  have,  however,  had  no  experience  myself  of  the  use  of 
this  drug  in  children.  In  the  rare  but  scarcely  questionable  cases  which 
are  described  by  some  as  reflex  epilepsy,  arising  from  such  occasions  as 
eye-strain,  &c,  we  should  search  for  any  probable  exciting  causes ;  cor- 
recting, for  instance,  marked  visual  errors,  if  possible,  or  endeavouring  to 
relieve  genital  irritability  by  careful  watching  or  by  removal  of  a  tight 
prepuce. 

Localised  Spasms. 

Under  this  title  I  shall  consider  briefly  certain  spastic  symptoms  of 
more  or  less  common  occurrence  in  children,  which  are  as  a  rule  local  in 
expression  and  often  in  origin. 

Nystagmus,  or  oscillations  of  the  eyeballs  in  either  a  lateral  or, 
more  rarely,  a  vertical  or  rotatory  direction,  is  in  childhood  mainly 
seen  in  connexion  with  blindness  or  much  impaired  vision,  as  in 
congenital  cataract,  corneal  opacities  or  optic-nerve  defect ;  with  intra- 
cranial tumours,  especially  those  involving  the  cerebellar  and  pontine 
regions ;  with  chronic  hydrocephalus  and  sometimes  acute  meningitis  ; 
with  many  cases  of  the  "  nodding-spasm  "  presently  to  be  noted ;  with 
some  apparently  epileptic  convulsions ;  and  with  the  rare  affections 
known  as  "  disseminated  sclerosis  "  and  "  Friedreich's  disease."  When 
constant  and  increased  by  fixation  of  the  gaze  on  a  distant  object, 
it  is  generally  a  sign  of  organic  nerve-disorder,  with  the  probable  ex- 
ception of  its  concurrence  with  nodding-spasm  or  with  some  cases  of 
convulsions.  More  or  less  rapid  lateral  nystagmus,  however,  is  some- 
times seen  in  normal-eyed  persons,  including  children,  when  they  are 
interested  or  excited,  and  may  then  be  almost  constant ;  but,  as  far  as  I 
know,  this  form  is  always  to  be  checked  by  voluntary  fixation  of  the 
gaze.  I  am  informed  by  Dr.  Hughes  Bennett,  to  whom  I  mentioned 
this  observation,  that  he  has  noticed  this  phenomenon  repeatedly  in 
students  under  oral  examination.  I  have  notes  of  one  marked  case  of 
nystagmus  in  a  child  of  two  who  had  suffered  from  very  frequent 
convulsions,  without  discoverable  exciting  cause,  since  the  age  of  three 
months.  The  child  was  slightly  rickety,  but  had  no  further  symptom 
of  nervous  disorder.  She  improved  much  after  a  month  in  hospital,  the 
convulsions  ceasing  and  the  nystagmus  becoming  much  less. 


SPASMODIC  DISORDERS.  243 

Nodding-spasm,  or  head-jerking,  is  in  my  experience  a  somewhat  rare 
affection.  Dr.  Hadden  however  saw  twelve  cases,  during  two  years' 
practice  at  the  Hospital  for  Sick  Children,  according  exactly  with  such 
as  were  described  by  Henoch  in  185 1  and  subsequently,  and  by  other 
observers.  The  affection  is  marked  by  constant  or  intermittent  nodding, 
lateral,  or  rotating  movements  of  the  head,  rhythmical  or  jerky,  and 
usually  accompanied  by  nystagmus  of  one  or  both  eyes,  either  vertical, 
lateral  or  rotatory.  The  nystagmus  is  of  far  more  rapid  rhythm  than 
the  movements  of  the  head,  and  is  generally  increased  when  the  head  is 
forcibly  held.  Henoch  attributes  this  affection  to  nerve-irritation  from 
teething  and  probably  other  reflex  causes.  Strabismus  is  but  rarely 
observed.  Nearly  all  the  subjects  are  under  two  years  old,  and  most 
are  first  attacked  between  the  ages  of  six  and  twelve  months ;  but  the 
symptom  has  been  sometimes  noted  long  before  the  earliest  teething- 
time,  and  Henoch  quotes  a  case  of  twelve  years  old.  From  four  out 
of  five  of  Dr.  Hadden's  detailed  cases,  and  a  few  which  I  have  seen 
myself,  in  which  there  were  either  convulsions  or  losses  of  consciousness 
with,  sometimes,  lateral  deviation  of  the  head  and  eyes,  it  would  seem 
that  this  affection  has  alliances  with  the  epileptic  condition,  or  at  least 
points  to  great  irritability  of  the  nerve-centres  usually  well-organised  in 
early  life.  I  am  also  inclined,  with  Dr.  Hadden,  to  include  in  the  same 
clinical  category  a  few  instances  I  have  seen  of  unexplained  nystagmus 
without  head-jerking.  For  a  more  detailed  account  of  these  cases 
I  refer  to  Henoch's  Lectures  on  Diseases  of  Children  and  to  Dr. 
Hadden's  paper  in  the  Lancet  for  June  1,  1890.  The  prognosis  is 
usually  good  as  regards  this  symptom,  and  I  know  nothing  better  to 
suggest  for  medicinal  treatment  than  the  use  of  the  bromides. 

There  is  some  distinction  to  be  made,  though  not  perhaps  so  great  as 
taught  by  the  above-quoted  observers,  between  this  affection  and  that 
Avhich  has  long  been  known  as  "  eclampsia  nutans  "  or  the  "  salaam  con- 
vulsions," where  the  movements  take  place  in  distinct  paroxysmal  attacks, 
consciousness  is  lost,  and  the  upper  part  of  the  body  as  well  as  the  head 
is  bent  forwards  with  rapidly  successive  jerks.  Henoch  says  that  these 
cases  always  end  fatally. 

I  may  mention  lastly  that  cases  of  frequent  slow  swaying  forwards  of 
the  body  are  often  seen  in  quite  young  children  not  necessarily  other- 
wise affected.  Some  of  them  have  been  referred  to  uneasiness  of  the 
genital  organs ;  but  in  several  which  I  have  observed  I  have  found  no 
local  cause  for  any  irritation. 

Torticollis  or  "  wry-neck"  is  almost  always  of  the  tonic  form  in  child- 
hood, the  permanent  clonic  variety,  or  ordinary  spasmodic  wry-neck,  being 
practically  a  disorder  of  later  life.  The  usually  temporary  jerking  of 
the  head,  from  contraction  of  the  sterno-mastoid  or  other  muscles  as  a 


244  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

part  of  nervous  habit,  may  concehrably,  if  continued,  account  for  a  few 
chronic  cases  of  torticollis  otherwise  unexplained.  Of  this  I  have  seen 
one  possible  instance.  The  most  usual  cases,  other  than  surgical,  of  this 
disorder  in  children,  are  either  of  the  acute  form  due  to  cold,  and  then 
to  be  regarded  as  an  extreme  form  of  "  stiff  neck ; "  or  of  the  chronic 
variety,  which  may  result  from  the  acute,  or  may  perhaps  be  due  to  such 
reflex  causes  as  carious  teeth,  but  often  appears  to  be  idiopathic  or  a 
simple  neurosis.  I  question  whether  the  affection  is  ever  directly  caused 
by  rheumatism  properly  so-called ;  for,  although  I  construe  the  sympto- 
matology of  rheumatism  in  childhood  as  widely  as  possible,  I  cannot  from 
my  experience  regard  torticollis  as  either  an  incident  in  acute  rheumatism 
or  as  an  indication,  from  any  of  its  associations,  of  the  rheumatic  diathesis. 
Congenital  wry-neck  is  always  tonic  and  chronic,  due,  probably,  to  ab- 
normal position  of  the  head  in  foetal  life  or  to  some  faulty  development 
of  the  vertebral  or  neuro-muscular  structures.  It  is  said  that  the  so- 
called  "  sterno-mastoid  tumour,"  sometimes  seen  in  infants  obstetrically 
injured,  and  due  to  extravasation  of  blood,  may  lead  to  torticollis.  Such 
cases,  however,  usually  recover  spontaneously.  Caries  of  the  vertebrae, 
glandular  abscesses  in  the  neck,  and  other  injuries,  such  as  cicatrisation 
after  burns,  must  be  remembered  among  extraneous  causes  of  torticollis. 
Treatment  must  be  directed  towards  removal  or  diminution  of  any 
visible  or  suspected  cause  of  the  affection.  The  congenital  cases  may 
often  be  cured  by  manipulation  or  tenotomy.  Acute  cases  as  a  rule 
recover  quickly  with  rest  and  warmth.  Chronic  cases  from  whatever 
cause  arising  are  usually  of  bad  prognosis,  though  on  the  whole  more 
likely  to  improve  than  in  the  adult,  especiaUy  when  apparently  idio- 
pathic. There  is  nothing  either  in  the  medical  or  surgical  treatment 
of  torticollis  which  is  special  to  childhood. 

Other  spasms  in  great  variety  are  seen  in  children.  They  are 
generally  to  be  regarded  as  signs  of  nervous  instability ;  are  often, 
though  by  no  means  always,  associated  either  individually  or  heredi- 
tarily with  hysteria,  chorea,  epilepsy,  migraine  or  other  neuroses ;  and 
sometimes  last  through  life.  Of  this  class  are  twitchings  of  the  eye- 
lids, scalp  and  nose,  of  muscles  of  other  parts,  and  multiform  jerkings 
of  the  head  and  shoulders  often  described  under  the  inaccurate  name 
of  "habit-chorea."  Sudden  and  oft-repeated  expiratory  acts,  often  with 
a  short  gruff  cough,  sometimes  occur,  of  which  I  have  seen  several 
examples  mostly  connected  with  a  neurotic  history.  One  was  in  an 
epileptic  boy  of  ten,  otherwise  quite  healthy.  These  phenomena  are 
frequently  occasioned  by  ill-health,  general  nervous  disturbance  or  local 
irritation,  and  may  pass  away  on  the  removal  of  the  excitant.  Some- 
times in  similar  clinical  association  are  seen  sudden  contortions  of  the 
extremities  and  even  of  half  the  body,  or  still  more  extended  convulsive 


SPASMODIC  DISORDERS.  245 

movements,  unaccompanied  by  any  disturbance  of  consciousness.  These 
cases  have  been  named  by  Henoch  "chorea  electrica"  or  "lightning 
spasm.''  The  knee-jerks  and  other  reflexes  in  such  children  are  usually 
excessive,  and  are  sometimes  attended  by  more  wide-spread  spasm. 
Closely  allied  to  these  spasms  in  children  are  occasional  cases  in  adults 
which  I  have  seen,  marked  by  multiform  contractions  and  highly- 
excitable  reflexes  amounting  often  to  clonus,  unassociated  with  any 
evidence  of  organic  disease  or  with  the  mental  phenomena  of  hysteria, 
and  often  ending  in  complete  recovery.  The  "  para-myoclonus  mul- 
tiplex "  of  Friedreich,  which  is  mainly  an  affection  of  the  large  muscles 
in  connexion  with  the  trunk,  seems  to  be  of  this  genus ;  as  also  does 
a  case  published  by  Hughes  Bennett  in  the  July  number  of  Brain 
for  1886. 

The  prognosis  in  most  of  these  various  cases  of  local  spasms  in 
childhood  is  good  in  proportion  to  the  slightness  or  absence  of  other 
and  graver  nervous  disorders,  and  the  possibility  of  suitable  treatment. 
Discoverable  causes  of  local  irritation  of  the  part  affected  often  exist ; 
such  as,  for  instance,  discomfort  from  clothing,  or,  as  in  the  case  of  the 
winking-spasm,  a  tendency  to  conjunctivitis,  which  is  not  seldom  the 
effect  of  late  hours  and  noxious  gases.  From  experience  of  many  cases 
of  all  grades,  I  am  sure  that,  as  a  rule,  the  child's  attention  should  not 
be  frequently  directed  to  the  spasms  ;  and  I  quite  agree  with  a  writer  on 
tills  subject  who  teaches  that,  when  the  movements  are  more  or  less 
controllable  by  the  will,  reward  for  improvement  is  much  more  successful 
than  punishment  for  continuance  of  the  habit.  These  children  are 
mostly  neurotic  in  some  form  and  degree,  and  must  be  treated  on  the 
best  principles  of  mental  and  physical  hygiene.  Regulated  bodily 
exercise,  as  much  out  of  doors  as  possible,  and  gymnastics  suited  to  the 
child's  age  are  very  helpful ;  and  daily  school  lessons  should  be  given, 
which  should  be  chiefly  oral  and  not  long  continued.  Prolonged  rest 
at  night  and  an  hour  or  two  of  sleep  in  the  day  should  be  encouraged, 
but  not  by  drugs;  close  and  gas-lit  rooms  must  be  tabooed;  and  all 
excitement  carefully  avoided.  In  weak  and  anaemic  children  the  mineral 
tonics,  especially  iron  and  arsenic,  are  of  much  use,  as  also  is  cod-liver 
oil  in  those  numerous  cases  where  fatty  foods  are  hardly  taken.  It  is 
but  in  the  severest  and  most  inveterate  cases,  and  those  complicated 
with  some  general  neurosis,  that  sedative  medicines  are  necessary  or 
advisable.  The  bromides  then  are  sometimes  of  signal  service  in  break- 
ing the  nervous  habit.  I  have  in  many  different  cases  seen  great 
improvement,  and  cure  with  no  subsequent  relapse,  as  the  result  of  a 
short  course  of  these  medicines.  Two  boys,  aged  about  ten,  suffering 
from  very  frequent  expiratory  spasm  of  several  months'  duration,  the 
one  slightly  epileptic,  the  other  of  double  asthmatic  heredity,  but  both 


246  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

otherwise  in  good  health,  permanently  lost  their  trouble  after  daily 
taking  for  a  few  weeks  thirty  grains  of  ammonium  bromide. 

In  a  few  cases  of  long-continued  jerky  spasms  of  the  neck  and  face 
or  other  muscles  I  have  had  complete  and  permanent  success  by  the 
method  of  removing  the  patient  from  home  and  applying  some  irritating- 
treatment,  such  as  a  blister  or  seton,  to  the  part  affected.  Such  treat- 
ment, I  believe,  operates  by  means  of  a  mental  impression. 

Retraction  of  the  head  is  most  often,  when  of  any  persistence,  the 
signal  of  serious  cerebral  disease ;  and  is  sometimes  combined  with  tonic 
spasm  of  the  trunk-muscles,  causing  excessive  opisthotonus.  It  occurs 
very  frequently  in  basic  cerebral  meningitis  from  any  cause,  with  or 
without  extension  to  the  spinal  cord,  the  symptoms  in  the  purely  basic 
cases  being  probably  due  to  the  prevalent  ventricular  effusion ;  in  many 
advanced  instances  of  intra-cranial  tumour,  especially  in  the  cerebellar 
region ;  and  in  some  of  chronic  hydrocephalus.  I  have  seen  it  in  a 
marked  degree  in  connexion  with  some  ill-explained  cases  of  general 
rigidity  with  wasting,  which  may  recover,  although  usually  with  impair- 
ment of  mental  functions.  In  one  case,  however,  of  a  child  of  two  years 
old  the  occiput  was  retracted  on  the  spine  for  many  weeks,  and  there 
was  extreme  wasting  with  great  rigidity  of  all  extremities,  followed  by 
a  very  gradual  recession  of  all  symptoms  and  ultimately  perfect  recovery 
with  intelligence  apparently  intact. 

As  a  rule  lasting  head-retraction  means  organic  disease,  and  my 
experience  of  autopsies  in  many  cases  where  this  symptom  existed 
tends  to  show  that  the  pathological  constants  are  either  basic  and 
cervical  meningitis,  tubercular  or  otherwise,  or  excess  of  fluid  in  the 
cerebral  ventricles.  In  many  cases  no  other  morbid  condition  is  found 
than  marked  ventricular  effusion.  Chronic  ventricular  effusion,  how- 
ever, at  least  when  of  insidious  origin,  may  certainly  exist  without 
retraction  of  the  head,  as  common  experience  amply  shows. 

It  must  be  remembered  that  the  head  is  often  retracted  in  cervical 
caries,  and  sometimes  in  cases  of  glandular  swellings  in  the  neck  or 
of  post-pharyngeal  abscess  pressing  on  the  larynx.  I  have  also  seen 
marked  retraction  several  times  after  falls,  without  any  other  nervous 
symptoms  than  those  due  to  general  shock.  It  is  here,  probably,  the 
result  of  muscular  strain.  Endeavours  to  replace  the  head  are  in  all 
such  cases  accompanied  by  pain;  and  as  a  general  rule,  when  a  local 
cause  is  in  question,  the  diagnosis  is  not  difficult. 

Simple  but  rigid  retraction  of  the  head  in  babies,  without  spasm,  and 
apparently  quite  unaccompanied  by  pain  on  attempts  being  made  to 
overcome  it,  is  often  observable  for  a  short  time  in  cases  of  temporary 
disorder,  whether  pulmonary  or  alimentary,  as  well  as  in  many  wasting 
infants  and  those  subject  to  convulsions.     I  have  sometimes  made  a 


THE  PARALYSES  OF  CHILDHOOD.  247 

provisional  diagnosis  of  meningitis  in  cases  such  as  these  (the  tempera- 
ture being  raised  in  many  instances),  where  perfect  recovery  took  place 
in  the  course  of  a  few  days.  Therefore,  without  any  other  cerebral 
symptom  or  evidence  of  further  disease,  head-retraction  is  by  no  means 
to  be  regarded  as  such  a  grave  or  even  fatal  sign  as  it  appears  to  some, 
even  when  all  local  causes  have  been  eliminated  as  far  as  possible. 


CHAPTER  II. 

THE    PARALYSES    OF    CHILDHOOD. 

Impairment  or  loss  of  motor  power  in  infants  and  young  children  may 
arise,  as  in  adults,  from  lesion  in  any  part  of  the  motor  tract,  whether 
cerebral,  spinal,  neural  or  neuro-muscular.  The  paralyses,  however, 
which  are  due  to  chronic  degeneration  in  brain  or  cord  are  mostly 
without  their  counterparts  in  early  life ;  while  others,  common  to  all 
periods,  such  as  many  of  those  caused  by  tumours  and  abscesses  or  by 
traumatic  and  other  extraneous  lesions  of  the  nerves  and  nerve-centres, 
have  no  clinical  or  pathological  characters  special  to  childhood. 

Infantile  Hemiplegia. 

Paralysis  on  one  side  of  the  body,  either  complete  or  partial  in  extent 
or  degree,  and  arising  from  lesion  or  defect  of  the  cerebral  motor  tract,  is 
often  met  with  in  early  childhood,  and  mainly  differs  from  the  classical 
hemiplegia  of  adults  in  being  less  often  of  that  typical  form,  marked  by 
involvement  of  the  arm,  leg,  face  and  tongue,  which  results  from  lesions 
in  or  near  the  internal  capsule,  and  in  being  much  more  frequently 
associated  with  both  initial  and  subsequent  convulsions.  The  reason 
for  these  differences  lies  in  the  rarity  in  childhood  of  hemorrhage  or 
thrombotic  softening  in  the  basal  ganglia,  and  in  the  more  frequent 
situation  of  the  lesion  over  the  motor  surface  of  the  brain. 

One  of  the  chief  known  causes  of  hemiplegia  in  infants  is  meningeal 
haemorrhage,  which,  however,  from  its  irregular  distribution  over  the 
surface  of  the  convolutions,  frequently  produces  bilateral  symptoms.  It 
is  mostly  traumatic,  and  occurs  at  or  soon  after  birth  owing  to  protracted 
labour  or  the  use  of  instruments.  In  this  context  I  may  .perhaps  men- 
tion a  case  of  hemiplegia  with  rigidity  of  the  right  arm  and  leg  in  a 
child  of  seven  years  old  who  was  suffering  from  well-marked  purpura 
hemorrhagica.     The  paralysis  improved,  and  the  diagnosis  of  superficial 


248  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

haemorrhage  seemed  very  prohahle.  Tumours  in  the  motor  tract,  whether 
in  the  cortex  or  lower  down,  localised  meningitis,  vascular  changes  from 
thrombosis,  embolism  or  cerebral  haemorrhage,  and,  rarely,  abscesses  of  the 
brain  are  also  established  causes  ;  and  imperfect  development  of  the  motor 
cortex,  either  congenital  or  sequent  as  atrophy  on  meningeal  haemorrhage 
or  other  trauma,  has  been  several  times  observed. 

Owing  to  the  rarity  of  recent  necropsies  in  hemiplegia  in  children,  the 
causes  in  numerous  cases  are  matter  of  conjecture.  Tumours,  especially 
tubercular  and  cortical,  are  doubtless  the  origin  of  some  cases  otherwise 
at  first  unexplained,  as  was  evidenced  by  the  case  of  a  boy  of  two  years 
old  under  my  care  in  hospital,  with  left  hemiplegia  beginning  with  con- 
vulsions, who  was  readmitted  after  a  year  with  recurrent  convulsions  and 
the  signs  of  meningitis.  At  the  post-mortem  we  found  small  caseous 
masses  of  tubercle  in  the  upper  Eolandic  region  on  the  right  side,  and 
recent  tubercular  meningitis.  Arterial  embolism  is  a  well-recognised 
though  not  frequent  cause  of  hemiplegia  in  children,  and  may  sometimes 
be  confidently  diagnosed  in  recent  endocarditis,  or  conjectured  in  some 
cases  of  marked  stasis  in  the  pulmonary  circulation.  I  have  notes  of 
a  case  of  rheumatic  fever,  with  endocarditis  and  chorea,  where  sudden 
hemiplegia,  occurring  first  on  the  right  side  with  aphasia  and  soon  after 
on  the  left,  allowed  no  doubt  of  the  diagnosis  of  double  embolism. 
Haemorrhage  other  than  meningeal  is  but  rarely  proved  in  childhood, 
but  it  may  occur  from  syphilitic  disease  of  vessels,  and  in  a  growing 
tumour ;  and  either  haemorrhage  or  thrombosis  is  the  possible  explana- 
tion of  those  cases  of  hemiplegia  which  take  place  during  or  soon  after 
measles,  scarlatina  and  other  acute  infectious  diseases.  Among  other 
examples  of  this  I  may  quote  a  typical  hemiplegia  of  capsular  origin, 
occurring  three  weeks  after  the  onset  of  severe  measles  in  a  child  of 
fifteen  months.  There  was  some  rigidity,  but  all  symptoms  disappeared 
in  four  months.  Thrombosis  of  the  right  middle  cerebral  artery,  without 
heart-disease  or  embolism,  was  found  by  Dr.  Abercrombie  in  a  case  of 
sudden  left  hemiplegia  in  a  boy  of  six  years  old  with  diphtheria ;  and 
thrombosis  of  the  vessels  from  syphilitic  disease  has  frequently  been 
reported.  The  sudden  hemiplegia  sometimes  occurring  in  whooping- 
cough  may  be  due  to  haemorrhage  from  increased  vascular  pressure,  with 
or  without  anatomical  change  in  the  walls  of  the  vessels.  Many  cases 
of  infantile  hemiplegia  with  convulsions  may  probably  be  explained, 
according  to  the  ingenious  and  reasonable  theory  of  Dr.  Gowers  (who 
argues  from  the  frequent  sinus-thrombosis  of  infancy),  by  the  occurrence 
of  thrombosis  in  cortical  veins;  and  the  hypothesis  of  Strumpell,  who 
reasons  from  the  sclerosed  and  atrophied  patches  not  seldom  seen  in 
the  young  brain  and  quotes  that  class  of  hemiplegias  which  begin,  as 
infantile  spinal  paralysis  often  does,  with  febrile  symptoms,  that  primary 


THE  PARALYSES  OF  CHILDHOOD.  249 

localised  inflammation  of  the  grey  matter  may  cause  cerebral  palsy,  is 
not  to  be  disregarded,  although  lacking  anatomical  proof. 

It  is  possible,  therefore,  to  diagnose  the  cause  of  hemiplegia  in  a  few 
instances,  and  to  guess  at  it  in  many  others  from  its  mode  of  onset; 
but,  seeing  that  in  adult  cases  with  much  more  definite  pathology  we 
frequently  mistake  haemorrhage,  thrombosis  and  embolism,  I  do  not 
regard  this  question  as  of  much  practical  importance. 

Clinically  infantile  hemiplegia  begins  in  most  cases  with  convulsions, 
generally  of  the  unilateral  type,  and  with  loss  of  consciousness.  Eigidity 
of  the  paralysed  limbs  sets  in  usually  very  soon,  the  joints  of  the 
upper  extremity  being  most  often  flexed,  and  the  foot  in  the  position  of 
equino-varus.  Convulsions,  both  unilateral  and  general,  tend  to  recur ; 
they  are  in  many  cases  strictly  epileptic,  and  may  remain  after  the  para- 
lytic symptoms  have  largely  or  quite  disappeared.  Mental  deficiency 
of  various  degrees  is  very  frequent,  especially  in  the  earliest  and  con- 
genital cases ;  so  also  is  marked  abnormality  in  the  shape  and  size  of  the 
skull,  many  of  these  infants  being  microcephalic.  After  a  more  or  less 
lengthened  period  wasting  of  the  rigid  and  paralysed  limbs  frequently 
sets  in,  and  there  may  be  marked  surface  coldness  and  venous  congestion. 
The  growth  of  the  limbs  is  also  often  arrested.  In  cases  other  than 
congenital  sudden  onset  is  accompanied  sometimes  by  marked  pyrexia 
without  further  specific  signs ;  and,  as  we  have  seen,  the  attack  may 
arise  in  the  course  or  sequel  of  many  acute  diseases.  I  have  several 
times  seen  true  aphasia  in  quite  young  children ;  in  one  case  at  the  age 
of  two  years.  Left  hemiplegia  with  aphasia,  stated  by  some  and  sup- 
posed by  others  to  be  more  frequent  in  children  than  in  adults,  I  have 
not  as  yet  observed.  The  rigidity  seen  at  first  usually  disappears  in 
sleep,  and  is  notably  increased  by  forcibly  moving  the  linibs.  Later 
on  in  bad  cases  there  is  often  permanent  contraction.  Fine  tremor,  or 
ampler  spasms  on  movement  of  the  affected  limbs,  and  the  constant 
movement  generally  called  "  athetosis  "  are  not  infrequently  seen.  These 
latter  movements,  slow,  irregular,  and  unlike  either  choreic  or  convul- 
sive spasm,  affect  the  upper  extremity,  and  mostly  the  fingers,  which  are 
constantly  working  in  a  vermiform  manner.  They  have  also  been 
inaccurately  named  "  post-hemiplegic  chorea,"  and,  far  more  appro- 
priately, as  preventing  confusion  with  other  disorders,  "mobile  spasm.'*' 
In  adults  this  symptom  has  generally  been  found  in  connexion  with 
softening  in  or  near  the  optic  thalamus ;  but  it  appears  certain  from 
general  pathological  knowledge  that  the  various  forms  of  mobile  spasm 
with  hemiplegia  may  be  due,  like  the  chronic  rigidities,  to  lesions  in 
any  position  which  interfere  with  the  fibres  of  the  pyramidal  or  motor 
tract. 

Cerebral  paralysis  is,  broadly  speaking,  marked  off  from  the  spinal 


250  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

paralysis  of  infancy  by  increased  reflexes ;  slight  and  slow,  instead  of 
rapid,  wasting  ;  rigidities  ;  normal  electrical  reactions  ;  hemiplegic  distri- 
bution •  and  frequently  convulsive  origin. 

The  prognosis  in  hemiplegia  depends  largely  on  the  diagnosis  of  the 
cause,  which,  we  have  seen,  is  often  a  matter  of  much  difficulty.  Con- 
genital cases  occurring  with  convulsions  mostly  involve  idiocy ;  and 
frequent  convulsions  in  any  case  may  pass  into  epilepsy  and  be  accom- 
panied by  some  mental  impairment.  Slight  congenital  cases,  however, 
may  improve  or  perhaps  recover ;  and  I  have  seen  at  least  two  non-con- 
genital ones  recover  where  convulsions  had  been  frequent  and  rigidity 
marked.  Frequent  convulsions  with  monoplegise  point  to  cortical  lesion, 
which,  being  often  tubercular,  may  be  ultimately  followed  by  meningitis. 
The  typical  form  of  capsular  hemiplegia  is,  both  as  to  its  causes  and 
prognosis,  similar  to  that  which  affects  adults,  and  the  forecast  is  here 
more  favourable  than  in  the  larger  class  of  cases  due  to  affection  of  the 
cortex ;  for  the  lesion  may  be  but  small  and  the  mental  faculties  little  if 
at  all  impaired.  It  is  common  to  find  the  paralysis  of  face  and  leg- 
disappearing  rapidly,  affection  of  the  arm  alone  remaining.  In  acute 
cases  prolonged  apathy  and  coma  are  of  the  worst  augury.  I  maj^  men- 
tion here  that  the  temporary  paralysis  of  the  limbs  seen  after  many  and 
severe  epileptic  attacks  does  not  occasion  prolonged  difficulty  either  in 
diagnosis  or  prognosis. 

It  follows  from  the  prevailing  permanency  of  these  affections,  from 
whatever  cause  arising,  that  the  field  of  treatment  is  very  small.  It  is 
rare  that  medical  aid  is  at  hand  before  the  initial  convulsions  are  over ; 
but,  when  possible,  these  should  be  checked,  according  to  the  methods 
already  mentioned,  without  waiting  to  make  a  diagnosis.  The  child 
should  be  kept  perfectly  quiet,  and  bromide  of  ammonium  or  potassium 
should  be  given.  There  is  no  objection  to  ordering  iodide  of  potassium 
for  some  weeks,  even  in  the  absence  of  positive  evidence  of  syphilis ;  for 
morbid  processes  due  to  syphilitic  vascular  disease  may  possibly  thus  be 
checked.  Contracture  may  be  treated  by  frequent  shampooing  of  the 
limbs,  but  rarely,  in  my  experience,  with  more  success  than  by  the  pro- 
bably useless  faradic  current.  In  two  cases  of  mine,  of  doubtful  origin, 
which  made  marked  improvement,  no  medicinal  or  manipulative  treatment 
was  employed. 

Spastic  Paralysis. 

There  is  doubtless  a  small  class  of  cases,  in  infants  and  young  children, 
reminding  the  observer  at  first  sight  of  that  now  well-known  disease  of 
adults,  which,  owing  to  the  affection  being  chiefly  or  wholly  confined 
to  the  legs,  at  least  in  the  early  stages,  is  described  under  the  name  of 


THE  PARALYSES  OF  CHILDHOOD.  25  I 

"spastic  paraplegia."  The  chief  clinical  characteristics  of  this  malady 
in  adults  are  loss  of  power  accompanied  by  startings  and  rigidity  of 
the  limbs,  increased  knee-jerks,  and  ankle-clonus ;  while  there  is  usually 
no  wasting,  affection  of  the  sphincters,  or  impaired  sensibility.  These 
phenomena  are  frequent  enough  as  a  sequel  of  myelitis  with  descending 
degeneration  of  the  lateral  columns  of  the  cord;  but,  when  they  occur 
in  an  apparently  pure  and  idiopathic  form,  their  pathology  is  at  present 
uncertain.  Some  cases,  progressive  or  stationary,  are  referred  by  many 
to  a  primary  lateral  sclerosis;  while  others,  retrocedent  or  recovering,  are 
sometimes  classed  with  functional  disorders.  It  is  in  my  opinion  to  be 
regretted  that  the  cases  now  to  be  considered  should  ever  have  been 
described  under  the  name  given  to  the  adult  affection ;  for,  as  we  shall 
see,  in  but  few  of  them  are  the  symptoms  of  paraplegic  distribution 
only,  and  it  is  not  in  the  cord  but  rather  in  the  brain  that  we  must  look 
for  the  underlying  lesion  or  cause  of  the  symptoms.  Spastic  paralysis 
in  childhood,  not  only  in  its  narrower  but  also  in  its  wider  sense,  must 
be  regarded  as  due  to  lesion  or  disturbance  of  function  in  the  cerebral 
motor  tracts ;  and  is  thus  fittingly  considered  in  connexion  with  infantile 
hemiplegia. 

Hemiplegia,  as  we  have  already  seen,  is  most  often  accompanied 
by  chronic  spasm  in  infancy ;  and  one  at  least  of  its  causes,  namely 
meningeal  haemorrhage,  is  often  productive  of  bilateral  symptoms.  It 
is  known,  both  from  clinical  and  post-mortem  evidence,  that  many  cases 
of  congenital  or  very  early  spastic  paralysis  on  one  or  both  sides  of  the 
body  are  due  to  cortical  injuries  and  wasting  of  the  motor  convolutions 
sequent  on  the  lesion.  Further,  it  is  established  by  recorded  cases  l  that 
the  same  symptoms  may  result  from  imperfect  development  of  the 
motor  convolutions  on  one  or  both  sides.  These  considerations  have 
an  important  bearing  on  many  of  the  spastic  paralyses  of  infancy,  in- 
cluding those  which  have  been  named  "spastic  paraplegia."  Post- 
mortem examinations  of  the  least  complicated  cases  are  few.  I  have 
myself  seen  but  one,  in  a  markedly  microcephalic  idiot  of  nearly  three 
years  old,  where  the  motor  convolutions  were  strikingly  small  and 
abnormal  in  appearance. 

Spastic  paralysis,  other  than  hemiplegic,  in  infancy  is  generally  of 
congenital  or  very  early  origin;  the  arms  mostly,  and  the  trunk-muscles 
sometimes,  are  affected  as  well  as  the  legs ;  there  is  frequently  marked 
wasting  of  the  body  and  anaesthesia  of  varying  degree ;  and,  owing 
doubtless  to  cerebral  causation,  the  sphincters  are  often  spontaneous^ 
relaxed.  Microcephaly  and  congenital  idiocy  are  frequent  in  all  grades, 
as  also  are  convulsions,  which  in  non-congenital  cases  are  often  the  first 

1  See  Sharkey's  "Lectures  on  Spasm  in  Chronic  Nerve  Disease,"  Churchill,  1886, 
and  Ross's  case  in  Brain,  vol.  i.  p.  477. 


252  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

noticed  symptom  and  may  be  succeeded  by  mental  disorder.  The  large 
majority  of  the  whole,  and  nearly  all  the  congenital  cases,  show  signs 
of  some  mental  deficiency.  Strabismus,  nystagmus,  marked  tremors  on 
movement,  and  "  mobile  spasms  "  of  the  arms  as  well  as  the  hands  have 
all  been  observed  in  one  or  other  of  my  own  cases.  The  knee-jerk  is 
usually  much  increased,  but  the  rigidity  is  often  so  great  as  to  prevent 
the  phenomenon  of  ankle-clonus.  In  the  slighter  cases,  where  standing 
or  walking  is  possible,  the  rigidity  is  still  conspicuous,  the  gait  is  hopping, 
the  thighs  adducted,  the  feet  inverted,  and  the  pointed  toes  frequently 
catch  the  ground.  Most  cases,  however,  are  from  the  first  unable  to 
stand,  and  the  rigidity  is  excessive,  the  legs  often  crossing  one  another. 
Sometimes  the  limbs  are  all  in  rigid  flexion;  in  others  the  legs  are 
extended  while  the  arms  are  flexed. 

The  difference  in  the  extent  of  the  paralysis  and  its  accompaniments 
in  various  cases  must  depend  on  the  nature  of  the  original  lesion  or 
defect,  as  also  the  improvement  or  recovery  seen  in  some  instances. 
Some  cases  waste  extremely,  others  but  little  or  not  at  all ;  and  it  is 
conceivable  that  in  some  of  these  anomalous  cases  we  have  to  do  with 
spinal  infantile  paralysis  of  a  chronic  form.  The  electrical  test,  which 
would  be  of  great  value  here,  is  often  quite  impracticable,  and  always 
difficult  of  application  and  interpretation  in  young  children.  It  is 
possible,  in  cases  which  show  improvement,  that  there  is  slight  inflam- 
matory or  hgemorrhagic  effusion  in  the  meninges,  syphilitic  change  in 
the  arteries  leading  to  softening,  retrocedent  tubercular  growth,  or  even 
late  compensation  for  previously  arrested  cerebral  development.  One  very 
marked  case  I  saw  in  a  boy  aged  fourteen  months,  who  for  six  months 
had  had  rigid  spasm  of  all  extremities,  strabismus,  retracted  head  and 
frequent  convulsions.  After  many  weeks  in  bed  with  excessive  wasting 
he  gradually  improved,  and  after  six  months  seemed  well  in  all  respects. 
I  saw  him  again  after  ten  months  more,  when  careful  examination  failed 
to  detect  any  abnormality  of  mind  or  body.  In  another  case  of  an 
undoubtedly  syphilitic  infant  the  symptoms  apparently  began  at  the 
age  of  six  months.  After  about  five  months  in  hospital  the  limbs 
recovered,  and  the  child  seemed  well;  but  there  was  marked  mental 
deficiency. 

Sometimes  the  paralysis  is  accompanied  by  more  or  less  rhythmical 
movements.  I  saw  one  marked  example  of  this  in  a  girl  of  six  years 
old,  with  a  good  family  history,  where  the  affection  had  been  first  noticed 
a  short  time  after  birth.  She  had  "  athetosis,"  without  rigidity  of  arms, 
and  rigid  extension  of  legs.  Another  case  with  athetosis  of  arms  and 
complete  inability  from  birth  to  maintain  equilibrium,  though  with  no 
rigidity  or  other  symptoms,  may  be  referred,  I  think,  with  many  of  the 
spastic  cases  proper,  to  some  widespread  defect  of  cerebral  development. 


THE  PARALYSES  OF  CHILDHOOD.  253 

Occasionally  I  have  seen  cases  with  all  the  symptoms  of  the  disease 
known  as  "  multiple "  or  "  insular "  sclerosis,  which  may  undouhtedly 
occur  in  early  childhood;  hut  post-mortem  examinations  of  young  children, 
showing  the  disseminated  lesions  in  brain  and  cord  connected  with  these 
symptoms  in  adults,  are  not  numerous.  Many  cases,  however,  have  been 
published  under  this  title,  some  showing  the  "  typical "  symptoms,  others 
with  difficulty  distinguishable  from  cerebellar  or  other  tumours.  At  any 
rate  the  subject  of  definite  and  demonstrated  "  multiple  sclerosis  "  has  no 
special  claim,  in  my  opinion,  to  be  discussed  at  length  among  diseases  of 
childhood. 

It  is  probable  that  in  children  these  chronic  spastic  affections,  owing 
to  their  multiform  associations  and  differences  of  extent  and  degree, 
have  a  multiform  causation ;  but  it  seems  certain  that  in  all  cases  they 
are  due  to  deficiency,  destruction  or  pressure  in  some  part  of  the  motor 
tract  in  the  brain,  as  is  evidenced  also  by  numerous  cases  of  brain- 
tumour,  especially  of  the  pons  or  of  the  cerebellum  pressing  on  the  pons, 
with  spastic  paralysis  of  limbs.  In  such  cases,  however,  as  are  unaccom- 
panied by  any  evidence  of  localised  brain-disease,  by  microcephaly  or 
by  mental  deficiency,  setiological  diagnosis  is  very  obscure. 

In  spite  of  several  anomalous  cases  of  tremors  on  movement,  without 
rigid  spasm,  which  I  have  often  thought  are  probably  slight  examples  of 
the  somewhat  heterogeneous  class  of  affections  we  have  been  considering, 
as  well  as  of  a  few  others  with  marked  and  wide-spread  rigidity,  and 
of  the  improvement  of  some  of  the  numerous  congenital  cases  usually 
referred  to  under  the  title  of  "spastic  paraplegia,"  the  prognosis  on 
the  whole  must  be  very  grave,  especially  when  the  affection  is  of  long- 
standing. It  is  very  rarely  that  this  set  of  symptoms,  dating  from 
infancy,  is  seen  in  adults ;  the  patients  tending  to  die  young  from  various 
causes. 

It  need  scarcely  be  said  that  treatment,  in  consequence,  must  be 
almost  vain.  We  may  try  antisyphilitic  remedies  in  all  doubtful  cases, 
but  with  scarcely  any  hope  of  success.  In  those  which  approximate  in 
appearance,  hoAvever  much  they  differ  pathologically,  to  the  spastic 
paralysis  of  adults,  but  are  however  not  progressive  and  may  last  in- 
definitely, exercise  should  be  enjoined ;  and  repeated  passive  flexion  of 
the  limbs  may  be  of  some  slight  use. 

Infantile  Spinal  Paralysis  op  Poliomyelitis  Anterior. 

By  this  title  we  denote  a  form  of  paralysis  which,  though  occasionally 
seen  at  all  times  of  life,  is  especially  incident  on  early  childhood,  most 
cases  beginning  during  the  period  of  the  first  dentition  and  but  few 
after  the  age  of  three  or  four  years.     The  limbs  are  especially  affected, 


254  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

the  lower  more  often  and,  as  a  rule,  more  gravely  than  the  upper  ;  the 
muscles  are  flaccid,  and  soon  begin  to  waste ;  and  the  paralysis  is  mostly 
of  sudden  onset,  attaining  its  highest  degree  almost  at  once.  Tested  by 
faradism,  the  excitability  of  the  paralysed  parts  is  found  to  be  much 
diminished  or  quite  lost ;  and  the  galvanic  current  soon  shows  the  re- 
action of  degeneration  to  be  present  in  greater  or  less  degree,  the  muscular 
contractions  being  slow,  and  either  equally  responsive  to  both  poles  or 
reacting  more  readily  to  anodal  than  cathodal  closure.  When  the  legs 
are  affected,  the  knee-jerks  are  lost ;  and  there  is  nearly  always  surface 
coldness,  and  often  an  appearance  of  venous  congestion  over  the  affected 
parts,  with  a  tendency  to  chilblains  and  ulcers  and  ready  reaction  to 
injuries  with  slow  healing.  The  functions  of  the  bladder  and  rectum 
are  usually  not  affected ;  but  in  one  extensive  case,  among  others,  that 
I  have  seen,  in  which  motor  power  was  lost  in  all  extremities  and  in 
the  neck  muscles  as  well,  there  was  complete  incontinence  of  urine  and 
fa3ces  for  a  week,  perfect  control  over  the  sphincters  not  being  regained 
until  another  week  had  passed,  by  which  time  the  neck  muscles  had 
recovered  and  the  paralysis  had  almost  disappeared  from  the  arms. 
The  legs  remained  paralysed  and  wasted  in  different  degrees.  Anaes- 
thesia is  rare,  occurring  only  as  an  occasional  complication,  and  pain 
and  tenderness,  though  not  seldom  present,  are  not  often  prominent  and' 
never  prolonged.  In  many  cases  where  little  or  no  improvement  is 
shown  the  whole  limb  is  stunted  in  growth ;  and  there  are  also  various 
deformities  owing  to  the  stretching  of  the  weakened  muscles  by  the 
weight  of  the  limb,  and  to  unantagonized  contraction  of  those  which 
are  unaffected. 

Sometimes  but  one  limb  or  certain  groups  of  muscles,  at  others  several 
limbs  or  even  the  trunk  or  neck  or  the  muscles  of  respiration  may  be 
involved ;  and  probably  in  most  cases  the  paralysis  is  greater  in  extent 
at  first  than  afterwards.  Some  improvement  usually  sets  in  very  soon, 
and  one  or  more  limbs  or  groups  of  muscles  may  rapidly  recover  while 
others  remain  partially  or  wholly  paralysed.  Eecovery  more  often  begins 
in  the  arm  than  the  leg  when  both .  are  paralysed.  In  fourteen  cases 
in  my  wards,  all  more  or  less  advanced  or  incurable,  of  which  I  have 
full  notes  on  this  point,  both  legs  were  affected,  though  unequally,  four 
times,  both  legs  and  one  arm  four  times,  one  leg  four  times,  one  arm  once, 
and  an  arm  and  leg  on  the  same  side  once.  The  detailed  records  of  others, 
dealing  with  extensive  statistics,  and  my  own  unrecorded  experience  of 
many  cases  formerly  seen  as  out-patients,  sufficiently  attest  the  predomi- 
nance of  leg  paralysis. 

Occasionally,  as  in  two  of  my  noted  cases  and  in  a  few  others  that 
I  have  seen,  the  paralysis  begins  insidiously  and  gradually  increases ; 
it  may  also  spread  after  a  while  to  fresh  parts  after  the  manner  of  what 


THE  PARALYSES  OF  CHILDHOOD.  255 

has  been  described  by  some  as  the  chronic  or  subacute  form  of  this 
affection  occurring  in  adults.  Dr.  Hughes  Bennett  and  Professor  Erb 
have  published  instances  of  this,1  and  it  is  probable  that  such  cases 
may  be  from  time  to  time  overlooked.  One  of  Dr.  Bennett's  cases  re- 
covered, but  the  prognosis  is  said  to  be  generally  bad  in  this  chronic  form. 
It  is,  moreover,  very  doubtful  whether  cases  of  this  nature  are  patholo- 
gically identical  with  the  acute  form  of  the  disease  under  consideration. 
I  have  seen  several  instances,  exclusive  of  hospital  in-patients,  which 
answered  to  the  so-called  "  temporary  paralysis  of  childhood,"  where 
perfect  recovery  took  place  in  the  course  of  three  or  four  weeks ;  and  a 
few,  seemingly  typical,  which  got  well  in  a  few  days.  It  is,  however, 
quite  open  to  doubt  the  diagnosis  of  such  cases ;  for,  without  wasting, 
coldness  of  surface  or  the  electrical  test,  important  elements  of  distinc- 
tion are  wanting.  It  must  be  remembered  that,  even  with  cases  in 
other  respects  typical,  the  electrical  test,  otherwise  so  valuable,  and 
especially  the  galvanic  current,  is  extremely  difficult  both  to  apply  and 
interpret  in  young  children. 

Frequent  as  the  cases  are  which  correspond  more  or  less  closely  to  the 
received  description  of  infantile  paralysis,  it  must  be  admitted  that  we 
are  much  in  want  of  more  accurate  observation,  both  as  to  the  clinical 
conditions  and  modes  of  onset,  before  we  can  form  a  perfectly  definite 
conception  of  the  disease  as  due  to  one  and  the  same  pathological  pro- 
cess. In  private  as  well  as  in  hospital  practice  most  patients  escape 
trained  observation  at  the  outset,  our  chief  reliance  for  information 
as  to  the  beginning  of  the  attack  being  perforce  placed  on  more  or 
less  vague  and  imperfect  reports ;  and,  as  we  shall  presently  see,  the 
^etiological  knowledge  we  have  from  morbid  anatomy,  highly  important 
though  it  be,  is  mainly  based  on  the  examination  of  long-standing 
cases. 

The  following  are  the  chief  conditions  and  accompaniments  of  the 
onset  of  cases  answering  to  the  usual  description  of  infantile  paralysis. 

Pyrexia  of  duration  varying  from  a  few  hours  to  several  days,  and 
unassociated  with  any  distinctive  symptoms,  very  frequently  precedes 
the  discovery  of  the  paralysis  ;  and  some  very  exceptional  cases  of  a 
severe  and  even  fatal  character,  accompanied  by  convulsions  and  sweating, 
have  been  reported  as  occurring  in  an  epidemic  form.2  The  typical 
paralysis  also  occurs  in  the  course  or  as  the  sequel  of  measles,  scarlatina 
and  other  specific  diseases.  In  three  out  of  sixteen  recorded  cases  in 
my  wards  there  was  a  definite  history  of  an  initial  feverish  attack  of 
a  few  days'  duration ;  in  a  fourth,  of  severe  vomiting  the  night  before 
the  paralysis  was  noticed ;  and  in  a  fifth  the  paralysis  appeared  on  the 

1  See  Brain,  vol.  vi.,  1883. 

2  Cordier,  Lyon  Medical,  Jan.  and  Feb.  1888. 


256  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

third  day  of  scarlet  fever.  I  have  also  in  my  memory  several  cases 
following  directly  on  measles ;  and  one,  of  an  apparently  complete 
although  mainly  temporary  character  (one  leg  only  being  affected  and 
almost  recovering  within  three  weeks),  which  occurred  in  a  child  of 
four  years  old  who,  with  three  others,  was  just  convalescent  from 
influenza.  It  is  possible  and,  according  to  some,  highly  probable,  that 
unnoticed  fever  may  frequently  occur. 

Convulsions  with  or  without  fever  are  often  reported  as  ushering  in 
the  paralysis,  and  sometimes  there  is  a  semi-comatose  condition  at  the 
onset.  I  have  seen  two  cases,  in  one  of  which  the  paralysis  followed 
on  protracted  convulsions  recurring  during  a  fortnight,  and  in  the  other 
immediately  on  a  single  fit.  Pain  and  tenderness  on  pressure  in  the 
affected  limbs  and,  indeed,  sometimes  in  the  body  generally  are  not 
very  rarely  reported,  but  seldom  last  long.  Doubtless  considerable 
general  pain  exists  at  the  outset  in  some  cases ;  and  this  symptom, 
especially  marked  in  the  back,  is  very  prominent  in  many  instances  of 
the  disease  in  adults.1  My  experience,  however,  teaches  me  that  marked 
pain  and  especially  tenderness,  evinced  mainly  or  entirely  on  movement 
of  the  affected  limb,  are  valuable  diagnostic  signs,  pointing  away  from 
the  affection  we  are  considering.  Falls,  or  blows  on  the  back,  are  often 
quoted  as  exciting  causes ;  but  the  frequency  of  these  accidents  in  early 
childhood  renders  a  causal  nexus  even  more  doubtful  here  than  in  the 
cases  of  antecedent  exanthems.  In  four  of  my  sixteen  cases  above  quoted 
a  fall,  and  in  one,  a  blow  on  the  back,  was  the  alleged  cause ;  in  one, 
however,  a  feverish  attack  of  two  days'  duration  intervened  between  the 
fall  and  the  paralysis,  and  in  another  there  were  convulsions ;  while  in 
one  only,  where  after  a  severe  and  stunning  fall  an  eventually  typical 
paralysis  was  observed  on  the  child's  regaining  consciousness,  could  the 
connexion  be  deemed  with  much  probability  other  than  coincidental. 
"  Catching  cold "  and  rheumatism,  properly  so-called,  are  among  the 
alleged  or  suggested  conditions  out  of  which  this  paralysis  arises.  There 
appears  to  be  some  evidence  sometimes  of  a  rheumatic  connexion,  either 
in  the  personal  or  family  history  of  the  patient ;  and  doubtless  many 
recorded  cases  have  followed  immediately  on  a  definite  chill.  A  child 
of  two  years  old,  whom  I  saw  several  times,  had  a  typical  paralysis  of 
paraplegic  distribution  a  few  days  after  suffering  from  severe  leg  pains 
immediately  following  a  prolonged  sitting  on  wet  grass.  In  this  context 
we  may  bear  in  mind  the  vulnerable  condition  of  the  nervous  system  in 
early  childhood,  and  the  vascularity  of  the  cervical  and  lumbar  enlarge- 
ments of  the  cord,  which  are  the  chief  seats  of  the  lesion  found  post- 
mortem.    Over-exercise  has  seemed  occasionally  to  be  the  precursor  of 

1  See  reports  of  two  cases  of  my  own  in  vol.  ii.  of  Westminster  Hospital  Reports, 


THE  PARALYSES  OF  CHILDHOOD.  257 

the  paralysis,  and  we  may  remember  here  that  the  disease  is  probably 
rare  in  the  first  year  of  life  and  frequently  attacks  robust  and  active 
children.  Caution,  however,  is  required  when  attempting  to  draw  any 
conclusion  as  to  the  nature  of  a  case  from  consideration  of  age,  for  the 
younger  the  subject  the  more  difficult  is  accurate  diagnosis.  Lastly,  heat 
has  been  suggested  as  one  of  the  conditions  of  the  affection,  the  majority 
of  cases,  according  to  most  authorities  who  have  collected  large  numbers, 
occurring  in  the  summer  months. 

No  alleged  or  probable  excitant  is  found  in  a  large  number  of  cases. 
I  have  seen  several  where  it  was  positively  stated  that  the  paralysis 
came  on  suddenly  when  the  child  was  in  perfect  health,  and  Ave  frequently 
hear  of  children  being  put  to  bed  well  and  found  paralysed  in  the  morn- 
ing. In  this  context  we  must  remember  also  the  chronic  cases  above 
mentioned,  where  weakness,  at  first  scarcely  noticed,  gradually  develops 
into  typical  paralysis  with  wasting  and  the  reaction  of  degeneration. 
Such  cases  as  these,  and  especially  the  sudden  ones,  are  very  striking, 
and  must  clearly  be  reckoned  with  when  we  endeavour  to  formulate  a 
rational  aetiology. 

Such  being  the  apparently  multiform  conditions  and  modes  of  origin 
of  this  affection,  the  lesson  taught  us  by  necropsies  of  many  old-standing 
and  a  few  recent  cases  is  a  valuable  contribution  to  the  question  of 
aetiology.  It  is  almost  certain  that  in  the  typical  cases  -with  wasting  the 
necessary  lesion  is  more  or  less  destruction  of  the  large  ganglion-cells  in 
the  anterior  cornua  of  the  spinal  cord,  and  that  the  morbid  process, 
though  it  be  found  in  some  degree  in  the  whole  length  of  the  cord  or 
may  even  involve  other  columns  as  well,  is  especially  concentrated  in 
the  cervical  and  lumbar  enlargements.  Corroborative  evidence  of  this 
is  afforded  by  cases  ha  adults  with  similar  symptoms  and  post-mortem 
lesions.  In  most  necropsies  there  has  been  sclerotic  overgrowth  of  the 
neuroglia  in  the  anterior  cornua,  more  or  less  invading  the  antero-lateral 
columns  or  other  parts  as  well ;  but  there  is  but  scanty  evidence  from 
necropsies  in  recent  cases  as  to  the  nature  and  cause  of  the  primary 
lesion.  Occasionally,  and  notably  in  Dr.  Charlewood  Turner's  case  at 
the  London  Hospital  examined  six  weeks  after  the  onset  of  the  paralysis, 
hemorrhagic  foci  have  been  found,  involving  the  special  regions  above 
mentioned.  In  this  case,  however,  there  was  anaesthesia  as  well  as  motor 
paralysis  of  the  lower  parts  of  the  body,  and  the  lesion  was  found  to  have 
invaded  the  posterior  columns  in  the  lumbar  enlargement.  In  a  case  of 
my  own,  aged  2^  years,  at  Westminster  Hospital,  sudden,  permanent  and 
typical  paralysis  of  the  left  leg,  followed  in  a  fortnight  by  paralysis  of 
the  right  leg  nearly  recovering  after  seven  weeks,  preceded  death  from 
tubercular  meningitis  by  about  eighteen  weeks.  Post-mortem  examina- 
tion showed,  besides  the  cerebral  meningitis,  marked  wasting  of  the  left 

E 


258  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

anterior  cornual  region  of  the  cord,  especially  in  the  lumbar  region,  where 
the  cells  were  replaced  by  fibrous  tissue ;  and  the  left  sciatic  nerve  was 
smaller  than  the  right  and  contained  a  large  quantity  of  withered  tubules. 
There  was  also  marked  affection,  observable  by  the  naked  eye  as  well  as 
by  the  microscope,  of  the  anterior  cornual  region  all  down  the  left  side  ; 
the  cells  in  the  dorsal  region  having  disappeared,  though  there  had  been 
no  marked  symptom  during  life  of  affection  of  parts  above  the  lumbar 
region.  The  multipolar  cells  in  the  right  side  of  the  cord  were  also 
much  diminished  in  number.  The  specimens  were  shown  by  Dr.  Hebb 
at  the  Pathological  Society  of  London  in  April  1889. 

As  regards  the  aetiology,  then,  of  a  large  number  of  cases  of  "  infantile 
paralysis,"  we  are  on  firm  ground  when  we  assume  that  the  primary 
cause  of  the  symptoms  is  disease  of  the  large  ganglion-cells  in  the  anterior 
cornua  of  the  cord,  which  are  known  to  preside  over  both  motor  and 
nutritive  functions.  In  endeavouring,  however,  to  connect  the  various 
modes  of  onset  with  the  cord  lesions  the  question  of  the  nature  of  these 
lesions,  whether  primarily  haernorrhagic  or  inflammatory,  at  once  meets 
us.  The  hypothesis  of  a  primary  wide-spread  and  acute  inflammation 
involving  a  large  extent  of  the  cord  would  cover  all  those  cases  which 
begin  acutely  with  fever  and  extensive  paralysis,  including  those  which 
are  marked  by  sensory  symptoms,  the  fever  being  regarded  as  sympto- 
matic ;  while  the  partial  improvement  and  remaining  weakness  of  limbs 
would  be  accounted  for  by  the  predominant  and  permanent  affection 
of  the  cervical  or  lumbar  enlargement  of  the  cord.  On  the  other  hand, 
the  cases  which  begin  suddenly,  unmarked  by  any  other  symptom  than 
paralysis  of  a  limb  or  limbs,  including  those  which  may  be  possibly 
due  to  traumatic  causes  and  over-exertion,  would  be  better  explained  by 
such  a  lesion  as  haemorrhage  into  the  relatively  vascular  region  of  the 
anterior  cornua.  It  may  be  suggested,  too,  that  the  changes  in  the 
blood  and  vessels  induced  by  the  febrile  process  which,  whether 
specific  or  not,  so  often  precedes  the  paralysis,  are  predisposing  causes  to 
haemorrhage.  We  are  not,  however,  in  a  position,  owing  to  our  very 
imperfect  knowledge  of  both  the  clinical  and  anatomical  phenomena 
at  the  outset,  to  formulate  a  comprehensive  theory  of  the  causation  of 
this  disease,  if  indeed  it  be  always  one  and  the  same.  We  must  re- 
member that  the  assumption  of  a  primary  poliomyelitis  leaves  much  of 
the  aetiological  question  unsolved ;  while  that  of  a  primary  haemorrhage, 
though  harmonising  with  a  far  greater  proportion  of  all  the  known 
clinical  phenomena  and  therefore  possessing  great  claims  on  our  con- 
sideration, is  but  little  supported  by  the  teachings  of  morbid  anatomy, 
however  much  we  may  be  inclined  to  insist  upon  the  probably  greater 
liability  to  such  an  accident  of  the  actively  growing  cord  of  childhood. 

While  we  are  justified,  therefore,  in  regarding  infantile  paralysis  as 


THE  PARALYSES  OF  CHILDHOOD.  259 

generally  due  to  disease  of  the  spinal  marrow,  we  must  remember  that  it 
is  almost  impossible  to  exclude  peripheral  neuritis  as  a  cause,  especially 
in  cases  accompanied  by  pain  aggravated  on  movement  and  by  much 
tenderness  in  the  affected  limbs,  which  may  increase  gradually  from  the 
beginning.  The  same  atrophy  and  altered  electrical  reactions  result 
from  both  cord  and  nerve  lesions.  From  what  we  know  of  peripheral 
neuritis,  however,  we  should  mainly  suspect  it  as  a  cause  in  childhood  in 
cases  where  a  single  limb  or  group  of  muscles  is  affected.  As  possibly 
bearing  on  the  question  of  the  spinal  pathogeny  of  this  affection  I 
would  call  attention  to  two  cases  of  infantile  paralysis,  reported  by  Dr. 
Coutts,  where  there  was  swelling  of  the  ankle-joint  in  the  affected  limb 
nearly  coincident  in  time  with  the  onset  of  the  paralysis.  Dr.  Coutts  is 
inclined  to  connect  these  cases  with  the  recognised  spinal  arthropathies 
described  by  Charcot  and  others. 

The  diagnosis  in  most  cases  seen  some  days  or  weeks  after  the  onset 
is  fairly  clear  ;  but,  before  atrophy  or  coldness  of  the  limbs  is  pronounced, 
or  when  the  electrical  test  is  either  inapplicable  or  gives  doubtful  or 
nearly  normal  results,  the  difficulty  is  often  very  great.  The  fever 
which  frequently  precedes  attacks  has  no  distinctive  marks,  so  that 
we  depend  for  diagnosis  on  the  paralytic  phenomena  alone.  Cerebral 
paralysis  will  usually  cause  no  diagnostic  confusion  to  those  who  are 
acquainted  with  the  well-marked  contrast  presented  by  these  two  affec- 
tions ;  and  it  is  equally  unnecessary,  in  my  opinion,  to  detail,  after  the 
manner  of  many  authors,  the  striking  differentiee  between  infantile 
paralysis  and  other  forms  of  well-marked  nervous  disorder. 

The  practical  difficulties  of  diagnosis  occur  where  children,  otherwise 
healthy,  are  more  or  less  suddenly  found  to  be  suffering  from  inability 
to  move  a  limb;  and  I  have  several  times  seen  this  condition  confi- 
dently diagnosed  as  infantile  paralysis  by  medical  observers  when  it 
was  due  to  an  accidental  muscular  strain  or,  occasionally,  to  periostitis, 
syphilitic  or  otherwise.  Pain  on  pressure  or  on  movement  of  the  appa- 
rently paralysed  limb  does  not,  as  we  have  seen,  at  first  exclude  the 
diagnosis  of  infantile  paralysis ;  when,  however,  it  is  marked  and  con- 
tinued we  need  scarcely  ever  express  the  fears  we  may  entertain,  but 
may  with  considerable  confidence  give  a  good  prognosis  while  enjoining 
perfect  rest  for  the  affected  limb.  Such  strains  as  these  are  often 
caused  by  careless  handling  of  a  baby,  and  the  leg  or  arm  may  hang 
almost  as  motionless  and  flaccid  as  in  a  typical  case  of  infantile  paralysis. 
Hip-joint  disease  need  only  be  mentioned  as  causing  frequent  diagnostic 
mistakes  which  careful  local  examination  should  always  preclude,  even 
apart  from  the  important  symptom  of  the  knee-jerk,  which  is  absent  in 
the  paralytic  disorder.  Peripheral  paralysis,  affecting  a  large  nerve  from 
stretching,  pressure  or  other  causes,  especially  when  one  group  of  muscles, 


260  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

such  as  the  peronei,  are  mostly  or  alone  affected,  and  unaccompanied  by 
much  pain,  may  give  rise  to  symptoms  like  those  of  the  spinal  disease ; 
and  in  such  cases,  when  we  are  unable  to  trace  a  distinct  injury,  the 
diagnosis  should  be  postponed  for  a  while.  The  palsies  which  date  from 
birth  and  are  due  to  intra-uterine  causes  or  to  obstetrical  manipulation 
or  instruments  are  usually  referred  with  ease  to  their  true  origin. 

Prognosis  depends  on  the  amount  of  improvement  made  after  the 
first  week,  when  the  paralysis  has  reached  its  fullest  extent,  until  about 
the  fourth  or  fifth  month.  The  nature  of  the  onset,  whether  accom- 
panied or  not  by  fever,  gives  no  help  to  our  forecast  of  the  ultimate 
result.  Limbs  or  groups  of  muscles  which  are  limp  and  powerless  at 
the  sixth  month  from  the  onset  will  probably  remain  so  for  ever,  and 
it  is  a  rule  almost  without  exception  that  muscles  which  quite  fail  to 
react  to  faradism  applied  to  the  nerve  after  six  weeks  from  the  attack 
may  be  regarded  as  permanently  paralysed.  Much  wasting  at  any  period 
is  of  very  bad  prognosis.  For  the  first  six  weeks,  however,  after  the 
attack,  during  which  period  the  paralysis  often  remains  nearly  or  quite 
stationary  or  its  retrogression  may  be  extremely  slow,  we  must  not  give 
too  grave  a  prognosis ;  for  great  and  rapid  improvement  or,  occasionally, 
even  complete  recovery  may  subsequently  result. 

Wasting  is  sometimes  much  obscured  by  a  quantity  of  subcutaneous 
fat.  In  these  cases  especially  the  electrical  tests  both  of  failure  of 
reaction  to  faradism  and  of  too  ready  or  altered  reaction  to  galvanism 
are  of  great  value.  "We  must  remember,  however,  that  during  the  first 
six  weeks  we  may  find  marked  reaction  of  degeneration  in  muscles  which 
subsequently  imjDrove  or  recover.  After  six  months  or  so,  when  defor- 
mities appear  owing  to  stretching  of  the  paralysed  muscles,  from  the 
weight  of  the  limb  and  to  unbalanced  action  of  the  healthy  ones,  or 
when  stunting  of  the  limb  is  established,  we  know  that  little  can  be 
hoped  for  but  some  measure  of  mechanical  or  surgical  relief.  There  are 
a  few  cases  on  record  seemingly  showing  that  improvement  may  some- 
times occur  with  treatment,  even  after  many  months  of  an  apparently 
stationary  condition  with  no  power  of  voluntary  movement  or  faradic 
contractility. 

Treatment  in  the  earliest  stage  is  rarely  practicable  for  the  reasons 
aforesaid ;  but  when  possible,  or  in  cases  where  the  disease  is  suspected, 
the  patient  should  be  kept  absolutely  still,  and  leeches  or  cupping- 
glasses  may  be  applied  along  the  spinal  column,  or  blisters  may  be  used 
in  the  same  region.  Later  on,  when  the  diagnosis  is  clear,  the  child 
should  still  be  kept  in  bed,  sedatives  such  as  the  bromides  being  adminis- 
tered in  case  of  much  restlessness.  After  six  weeks,  faradism,  with  a 
current  just  strong  enough  to  produce  contraction,  may  be  used  to  the 
affected  muscles  which  react  at  all,  and  the  interrupted  galvanic  current 


THE  PARALYSES  OF  CHILDHOOD.  26  I 

to  those  which  fail  to  respond  to  faradism.  Ten  minutes  at  a  time,  once 
or  twice  a  day,  is  enough  for  either  of  these  applications.  It  will  he 
found,  however,  in  most  cases  impossible  to  proceed  with  the  galvanic 
current,  owing  to  the  great  pain  it  so  often  causes  in  children,  and  even 
the  faradic  current  has  not  seldom  similar  and  other  practical  draw- 
backs. I  believe  that  passive  movements  of  the  affected  limbs,  with 
thorough  and  daily  repeated  shampooing  with  the  oiled  hand,  all  care 
being  taken  at  the  same  time  to  preserve  continuous  warmth  to  the  limb 
by  clothing  and  hot  bottles  in  the  bed,  are  not  only  more  practicable 
but  also  more  efficacious  in  every  way  than  the  electrical  treatment.  At 
any  rate,  though  I  have  often  ordered  the  manipulative  method  Avithout 
the  electrical,  with,  I  think,  beneficial  results,  I  would  never  recommend 
the  electrical  alone.  Whichever  line  be  adopted,  treatment  should  be 
persevered  in  for  at  least  a  year. 

The  general  nutrition  and  hygiene  of  the  child  should  be  carefully 
attended  to,  and  such  medicinal  "  tonics  "  as  iron,  strychnia,  arsenic  or 
cod-liver  oil  may  be  required  in  some  cases  from  time  to  time.  Every 
encouragement  to  use  the  weakened  limbs  should  be  given,  and  much 
can  be  done  in  this  direction  by  means  of  artificial  supports,  go-carts, 
wheeled  chairs,  and  other  mechanical  devices. 


Chronic  Paralyses  with  Atrophy  of  Muscles. 

Under  this  very  general  heading  I  include  certain  groups  of  cases 
of  marked  weakness  with  wasting  of  muscles,  which  begin  almost  always 
in  childhood  or  early  youth  and  are  characterized  by  insidious  onset  and 
sIoav  progress.  In  some,  with  apparently  stationary  periods  of  consider- 
able duration,  there  is  a  tendency  to  death  before  adult  age  from  general 
wearing-out  or  from  some  intercurrent  disease ;  in  others  there  is  some- 
times comparative  or  complete  arrest.  The  best  marked  group  with 
fairly  distinctive  clinical  characters  is  known  as  "  pseudo-hypertrophic  " 
(or  Duchenne's)  paralysis  ;  another,  smaller  and  less  clearly  definable, 
may  be  classed  generically  as  "  progressive  amyotrophy,"  and  diversely 
specified  as  differing  from  the  well-known  type-form  which  begins,  as 
a  rule,  in  the  small  muscles  of  the  hand.  Of  this  I  shall  allude  to  two 
species  known  respectively  as  the  "peroneal"  and  "juvenile"  forms. 
This  grouping  is,  however,  exclusively  clinical  and  confessedly  imperfect, 
and  by  no  means  implies  any  conclusion  or  theory  as  to  the  pathology  of 
these  affections ;  for,  although  there  may  be  reason  for  regarding  some  as 
due  to  primary  disease  of  the  muscles  and  others  to  disease  of  peripheral 
nerves  or  cord,  it  can  scarcely  be  said  that  an  exact  pathological  aetiology 
has  been  established  in  any  ;  and  I  shall  not  enter  here  into  any  discussion 
of  the  differential  diagnosis  of  myelopathies,  neuropathies  or  myopathies. 


262  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

In  most  of  this  probably  heterogeneous  class  of  affections  there  is 
usually  believed  to  be  a  strong  tendency  to  some  kind  of  hereditary 
transmission 

Pseudo-Hypertrophic  Paralysis. — This  affection  has  long  been  recog- 
nised from  its  marked  clinical  characters,  which  are  fully  described  in 
the  text-books  and  in  Gowers'  well-known  monograph.  It  begins  almost 
exclusively  in  childhood,  showing  itself  at  first  by  a  weakness  of  the 
lower  extremities,  which  causes  the  child  to  stand  with  his  back  arched 
forwards,  to  straddle  and  sway  in  walking,  to  fall  down  readily,  and  to 
rise  from  the  floor  and  mount  stairs  with  difficulty ;  later  on,  by  apparent 
enlargement  of  certain  muscles  and  wasting  of  others,  with  a  tendency  to 
"  pes  equinus  "  from  contraction  of  the  calf-muscles  or  weakness  of  their 
opponents,  and  by  marked  aggravation  of  all  the  symptoms  ;  and,  finally, 
by  inability  to  walk  or  stand,  with  extended  wasting  of  muscles,  includ- 
ing those  which  were  previously  enlarged.  The  paralysis  is  apparently 
proportionate  to  the  wasting,  and  is  not  necessarily  most  marked  in  those 
muscles  which  are  the  seat  of  enlargement.  The  general  health  is  usually 
good,  and  the  symptoms  may  remain  stationary  for  long ;  but  the  disease, 
once  clearly  established,  is  perhaps  always  progressive,  and  very  few  cases 
live  to  adult  age.  Death  usually  results  from  exhaustion  or  intercurrent 
disease  ;  but  our  knowledge  on  this  point  is  scanty,  as  most  cases  are  lost 
sight  of  by  their  recorders  long  before  the  end,  and,  from  loss  of  their 
characteristic  symptoms,  are  probably  unrecognisable  by  those  in  whose 
charge  they  die.  One  of  my  own  well-marked  cases,  dismissed  in  an 
apparently  stationary  condition,  was  re-admitted  under  a  colleague  more 
than  two  years  afterwards  without  a  trace  of  muscular  enlargement,  quite 
incapable  of  any  movement  owing  to  excessive  wasting  of  muscles,  and 
with  universal  rigidity  which  suggested  disease  of  the  antero-lateral 
columns  of  the  cord.  Without  the  previous  history,  the  nature  of  this 
case  would  entirely  have  escaped  notice.  The  boy  died  from  chest 
mischief,  but  a  post-mortem  was  not  permitted. 

This  disease  may  be  suspected  in  the  early  stage  from  the  straddling 
gait,  the  tendency  to  fall,  and  a  certain  difficulty  in  rising  from  the 
ground;  the  characteristic  manoeuvre  of  the  patient's  climbing  up  his 
legs,  to  assist  the  weakened  extensors  of  the  knee,  hip  and  spine, 
being  often  postponed  even  until  after  some  pseudo-hypertrophy  has 
shown  itself.  In  this  early  stage  a  marked  hardness  of  the  muscles 
which  may  afterwards  become  enlarged,  and  especially  those  of  the  calves 
and  buttocks,  may  sometimes  be  observed  and  is  an  aid  to  diagnosis. 
But  I  must  remark  here,  as  bearing  on  the  question  whether  this  affec- 
tion be  ever  recovered  from  or  arrested  in  an  early  stage,  that  I  have 

n  several  cases,  some  of  them  after  measles  or  other  febrile  diseases, 
:  symptoms  such  as  these,  irresistibly  reminding  one  of  pseudo- 


THE  PARALYSES  OF  CHILDHOOD.  263 

hypertrophic  paralysis,  have  lasted  for  weeks  and  completely  disappeared, 
and  others  which  have  neither  progressed  nor  shown  any  enlargement  of 
muscles.  I  have  seen,  besides,  a  boy  of  six  years  old  who  had  been  slow 
and  inactive  for  six  weeks  and  unable  to  run  for  one  week.  There  was 
marked  "lordosis,"  a  straddling  gait,  inability  to  rise  from  the  ground 
without  touching  the  knees,  and  notable  enlargement  of  the  calves  and 
buttocks.  The  skin  of  the  legs  was  mottled,  and  the  knee-jerk  was 
absent  on  the  right  and  very  slight  on  the  left  side.  After  six  weeks, 
during  which  time  I  had  not  seen  him,  all  these  symptoms  were  much 
less,  with  the  exception  that  both  knee-jerks  were  now  absent.  A  fort- 
night later  he  was  quite  well.  I  saw  him  finally  six  weeks  after  this, 
when  he  was  still  without  symptoms,  the  knee-jerks  were  both  present, 
and  he  walked  and  ran  with  ease. 

In  the  established  disease  almost  all  the  muscles  of  the  body,  including 
sometimes  those  of  the  face,  may  be  more  or  less  enlarged ;  but  as  a  rule 
the  most  striking  in  this  respect  are  the  calf  and  buttock  muscles,  the 
spinati,  and  the  deltoids.  The  pectorals,  latissimi  and  other  muscles  of 
the  upper  part  of  the  body  often  waste  both  early  and  rapidly.  The 
skin  is  most  often  mottled  over  the  affected  parts,  especially  after  pro- 
longed exposure.  It  has  been  often  stated  that  the  surface  temperature 
of  the  enlarged  parts  is  higher  than  that  of  the  rest  of  the  body  ;  but 
I  am  convinced,  from  repeated  and  careful  observations  in  four  well- 
marked  cases,  that  this  is  a  mistake.  The  simple  precaution  of  eliminat- 
ing the  disturbing  element  of  different  periods  of  exposure  by  altering 
the  order  of  observations  sufficiently  establishes  the  error  of  the  prevalent 
statement  on  this  point.  The  knee-jerks  are  said  to  be  lost  only  in  the 
later  stages.  I  found  them  present  in  one  case  of  seven  months'  standing, 
the  boy  having  been  quite  active  till  6 h  years  old  ;  absent  in  a  boy  of 
9  who  had  difficulty  in  walking  from  the  first,  when  he  was  15  months 
old ;  and  present,  though  slight,  in  a  boy  of  10  who  had  been  quite  well 
till  3  years  old.  Faradic  reaction  in  the  nerve-trunks  is  normal  till  very 
late,  and  then  only  diminished,  owing  probably  to  degeneration  of  the 
nerves  ;  in  the  muscles  it  is  always  lessened  from  the  resistance  caused 
by  the  morbid  fibrosis.  Galvanism  to  the  nerves  does  not  show  much 
change  till  late  in  the  disease  ;  but  to  the  muscles  produces  a  reaction 
diminished  in  proportion  to  the  wasting  of  muscular  fibre,  and  there  may 
be  a  slight  degree  of  the  reaction  of  degeneration.  In  two  of  my  cases  I 
found  that  the  faradic  reactions  in  affected  parts  were  altogether  normal, 
one  being  of  seven  months',  the  other  of  seven  years'  duration  ;  while  in 
two  more  of  several  years'  standing  there  was  diminution  of  reaction  to 
faradism  both  in  the  nerves  and  muscles  of  the  legs,  and  scarcely  any 
difference  between  the  anodal  and  cathodal  closure  contractions  with  the 
galvanic  current.     All  my  cases,  ineludhiLr  several  doubtful  ones  and  the 


264  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

probable  instance  of  recovery,  were  boys ;  and  in  none  was  there  any 
ascertainable  trace  of  heredity,  direct  or  collateral.  In  many  reported 
cases,  however,  it  has  been  found  that  the  disease  occurs  frequently  in 
the  same  family,  being  apparently  transmitted  through  unaffected  mothers 
to  their  sons.  Mental  deficiency  has  been  often  noted.  In  one  of  my 
cases  some  obtuseness  was  reported  from  school,  though  the  boy  appeared 
quite  intelligent  in  hospital ;  and  in  another  speaking  was  delayed  until 
the  age  of  five.  In  the  uncomplicated  disease  no  sensory  abnormality 
or  loss  of  control  over  bladder  or  rectum  finds  place. 

The  clinical  disease  is  certainly  not  congenital  of  necessity,  but  that 
there  may  be  a  latent  congenital  tendency  is  a  hypothesis  which  cannot 
be  disproved.  In  most  cases  no  exciting  cause  can  be  found,  and  I  regard 
as  merely  accidental  the  apparent  development  of  one  of  my  cases,  aged 
7  years,  out  of  a  definite  attack,  following  on  a  fit  and  fever,  of  infantile 
paralysis  of  the  left  and,  slightly,  of  the  right  leg  five  years  previously. 
The  right  leg  recovered  from  the  paralytic  attack  completely,  and  the  left 
to  a  great  extent ;  but  on  admission  there  was  marked  lessening  in  length 
and  bulk  in  the  whole  left  lower  extremity,  where  the  surface  temperature 
was  persistently  about  five  degrees  lower  than  over  the  rest  of  the  body. 
In  this  case  there  was  marked  wasting  of  the  pectorals  and  deltoids, 
although  the  "  spinate  "  and  "triceps"  muscles  were  bulky;  while  the  left 
calf  as  well  as  the  right  increased  by  f  inch  in  girth  during  six  months' 
stay  in  hospital.  Two  years  afterwards  the  boy  could  not  stand,  his 
deltoids  were  powerless,  and  his  buttocks  wasted ;  but  the  triceps  muscles 
and  the  calves  were  still  very  large. 

The  great  weight  of  recent  opinion  on  the  pathology  of  this  disease  is 
on  the  side  of  its  being  a  primary  myopathy ;  although  in  some  cases 
more  or  less  wasting  of  the  ganglionic  cells  in  the  anterior  cornua  of  the 
cord  and  other  morbid  appearances  have  been  found.  In  a  case  brought 
by  Dr.  Handford  before  the  Pathological  Society  in  1889  there  were  the 
usual  muscular  changes,  with  degeneration  of  the  diaphragm  and  heart- 
muscle,  and  marked  degeneration  and  atrophy  of  the  peripheral  nerves 
of  the  affected  parts,  which,  considering  the  absence  of  sensory  symptoms, 
probably  affected  the  motor  nerve-fibres  only  and  were  secondary  to  the 
muscular  degeneration.  The  cord  was  mainly  healthy,  although  there 
was  occasional  slight  degeneration  of  the  ganglion-cells  in  the  anterior 
cornua,  and  also  an  area  of  softening  in  the  lumbar  enlargement  apparently 
due  to  haemorrhage. 

The  muscular  changes  consist  in  great  increase  of  connective  tissue 
between  both  the  bundles  and  the  fibres  themselves.  There  may  be 
also  an  early  overgrowth  of  fat.  As  the  disease  progresses  much  fat  is 
deposited  in  the  newly-formed  connective  tissue,  and  the  muscular  fibres 
are  separated,  atrophy,  and  disappear.     Finally  all  muscular  structure 


THE  PARALYSES  OF  CHILDHOOD.  265 

may  be  obliterated,  and  the  newly-formed  fibrous  tissue  degenerates, 
leaving  nothing  but  fat  and  connective  tissue ;  and  the  fat  itself  may 
at  last  disappear.  The  morbid  process  is  essentially  the  same  in  the 
muscles  which  waste  from  the  first  and  in  those  which  have  a  stage  of 
enlargement,  and  the  pseudo-hypertrophy  is  mainly  due  to  fibrosis. 

The  diagnosis  of  this  disease  is  generally  easy  except  at  the  begin- 
ning. It  may  occasionally  be  confounded  with  some  of  the  rarer  forms 
of  progressive  atrophy  in  children  presently  to  be  noticed,  and,  as  I  have 
often  observed  and  as  Koss  points  out,  with  various  cases  of  retarded 
development  and  want  of  co-ordination,  with  or  without  signs  of  cerebral 
disease.  I  would  especially  remark  here  that  the  generalised  forms  of 
paralysis,  not  seldom  seen  after  diphtheria  and  probably  some  other 
diseases,  give  rise  to  some  of  the  symptoms  which  many  thoughtlessly 
regard  as  pathognomonic  of  pseudo-hypertrophy.  I  have  more  than  once 
seen  the  action  of  climbing  up  the  legs,  as  well  as  the  waddling  gait,  in 
clear  cases  of  diphtheritic  paralysis  which  perfectly  recovered,  where  doubt- 
less the  same  muscles  were  weakened  as  in  the  disease  we  are  considering. 
A  doubtful  diagnosis  may  possibly  be  cleared  up  by  extracting  a  small 
piece  of  muscle  with  one  of  the  instruments  invented  for  the  purpose 
and  examining  it  microscopically ;  but  even  when  repeated,  as  it  must 
always  be,  such  a  procedure  is  generally  unsatisfactory  in  its  result  and 
not  without  risk,  nor  is  it  a  worthy  cause  for  administering  the  anaes- 
thetic without  which  the  operation  is  inadmissible. 

The  only  hope  for  treatment,  ignorant  as  we  are  at  present  of  the 
cause  of  the  disease,  lies  in  the  possibility  of  aiding  any  natural  tendency 
there  may  be  to  arrest  or  recovery.  I  have  seen  cases  improve  consider- 
ably in  hospital  with  good  food  and  tonics,  but  one  at  least  of  these 
made  subsequently  steady  progress  downwards.  Duchenne  says  that  he 
arrested  two  early  cases  by  faradism ;  but,  in  the  light  of  the  case  quoted 
above  of  recovery  under  ordinary  tonic  treatment  from  symptoms  which 
seem  at  least  very  suggestive  if  not  identical  with  those  of  the  recognised 
disease,  such  a  statement  is  of  little  value.  I  would  recommend  in  all 
early  and  all  doubtful  cases  the  best  hygienic  conditions,  regulated  exer- 
cise, shampooing  of  the  affected  limbs,  and  arsenic,  iron,  cod-liver  oil,  or  a 
combination  of  these,  as  possibly  helpful  towards  improvement  or  cure. 

The  Peroneal  Type  of  Progressive  Amyotrophy. — This  affection  has 
been  clinically  isolated  of  late  years,  and  cases  in  point  have  been 
described  by  Leyden,  Ormerod,  Charcot  and  Marie,  Tooth,  Herringham 
and  others.  I  showed  at  the  June  meeting  of  the  Neurological  Society 
in  1890  three  cases  in  one  family,  recording  them  in  Brain  (vol.  xiii. 
p.  456)  ;  and  would  refer  the  reader  especially  to  Dr.  Tooth's  paper  in  the 
same  periodical  (vol.  x.  p.  243),  and  in  the  St.  Bartholomew's  Hospital 
Reports  (vol.  xxv.)  for  a  full  account  of  this  class  of  cases.    In  established 


266  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

cases  there  is  wasting  and  weakness  of  the  legs,  often  with  markedly 
diminished  sensibility ;  and  the  feet  are  in  the  "  varus  "  position.  At 
least  in  the  later  stages  there  is  absence  of  reaction  both  to  faradism 
and  galvanism.  .  Subsequent  to  the  leg  affection  there  is  wasting, 
with  or  without  anaesthesia,  and  loss  of  electric  contractility  in  the 
small  muscles  of  the  hands  which  ultimately  assume  the  claw-like 
appearance  of  ordinary  progressive  muscular  atrophy.  In  some  early 
cases  there  are  pains  with  tremors  and  unaltered  electrical  reactions, 
and  in  a  subsequent  stage  there  is  the  reaction  of  degeneration.  Here- 
dity, though  often  marked,  is  not  always  present.  Dr.  Ormerod's  cases 
and  my  own  were  both  groups  of  three,  consisting  of  father,  son  and 
daughter  ;  and  the  symptoms  in  all,  save  the  father  in  the  latter  group, 
set  in  immediately  after  an  attack  of  measles.  The  disease  seems  always 
to  begin  in  childhood  or  early  youth,  and  probably  affects  first  the 
small  muscles  of  the  foot.  Muscles  besides  those  already  mentioned 
may  subsequently  suffer ;  but  there  seems  to  be  no  doubt  that  many 
cases  are  arrested,  for  at  least  an  indefinite  time,  after  the  legs  and  fore- 
arms are  affected.  In  all  my  own  cases  the  muscles  of  nearly  all  the 
rest  of  the  body  were  normal  in  every  respect,  the  girl,  aged  1 7,  affected 
since  the  age  of  7,  having  been  no  worse  for  long,  and  the  father, 
aged  42,  first  affected  at  17,  having  been  in  a  stationary  condition  for 
many  years.  The  gait  in  all  these  cases  was  high-stepping  (not  spastic, 
as  at  first  sight  appeared)  owing  mainly  to  foot-drop  from  peroneal 
weakness ;  and  the  knee-jerks  were  present,  with  no  ankle-clonus. 

The  pathology  of  this  affection  is  not  certainly  known.  On  the  whole, 
considering  the  at  least  occasional  presence  of  fibrillary  tremors  in  the 
early  stages,  the  occurrence  of  pain  in  some  cases,  and  the  anaesthesia  in 
many,  a  primary  peripheral  neuropathy  seems  perhaps  to  be  indicated. 
Some  regard  the  lesion  as  situated  in  the  cord,  and  others  as  starting 
in  the  muscles.  Too  few  necropsies  have  been  published  for  the  estab- 
lishment of  any  anatomical  point  of  setiological  importance.  The  imme- 
diate antecedence  of  measles  in  the  cases  above  alluded  to  is  to  be 
remarked  in  connexion  with  other  forms  of  paralysis  apparently  excited 
in  the  same  way ;  but  it  can  only  be  regarded  as  a  favouring  condition 
for  the  neuro-muscular  breakdown  which  constitutes  the  disease.  There 
is  a  general  clinical  likeness  between  this  affection  and  pseudo-hyper- 
trophic  paralysis;  but  the  pathology  is  even  still  more  doubtful,  and 
nothing  of  value  can  be  said  on  the  matter  of  treatment. 

The  "Juvenile"  Type  of  Amyotrophy. — Of  this  form,  described  by 
Erb,  I  shall  say  but  little,  having  only,  with  one  exception,  seen  cases 
observed  and  published  by  others.  Dr.  Savill  showed  some  very  good 
examples  at  the  Neurological  Society  in  June  1890.  The  symptoms 
of  wasting  and  weakness  attack  first,  and  are  often  for  long  limited  to, 


THE  PARALYSES  OF  CHILDHOOD.  267 

the  shoulder  and  uppt  c  ana  and  the  buttocks  and  thighs  ;  there  is  lessen- 
ing or  loss  of  the  knee-jerks,  no  fibrillary  tremor,  and  no  reaction  of 
degeneration,  bnt  only  diminished  electric  contractility.  The  disease  is 
said  to  begin  in  later  childhood  or  early  youth.  In  some  cases  wasting 
of  the  face  and  tongue  has  been  observed,  and  in  others  almost  complete 
loss  of  the  muscles  which  extend  the  trunk  on  the  thighs,  producing 
an  extreme  degree  of  lordosis.  As  with  the  previously  described  cases, 
there  is  nothing  as  yet  approaching  to  certain  serological  knowledge  of 
this  affection,  which  has  only  clinical  claims  to  a  separate  position. 

"  Diphtheritic  "  Paralysis. 

In  a  considerable  proportion,  probably  amounting  to  one-fourth,  of  cases 
of  diphtheria  which  recover,  various  paralyses  are  apt  to  occur  which  are 
of  a  sufficiently  special  character  to  merit  the  clinical  title  of  diphtheritic 
paralysis.  Although,  however,  this  group  of  cases  is  known  to  us  chiefly 
by  its  relation  to  diphtheria,  it  must  be  acknowledged  that  instances  of 
similar  paralysis  are  found  where  there  is  no  history  or  evidence  what- 
ever of  diphtheria,  or  indeed  of  any  previous  disease  ;  and  that  some  seem 
to  follow  on  other  acute  affections.  I  have  seen  sufficiently  numerous 
examples  of  paralysis  of  the  so-called  diphtheritic  type  presently  to 
be  described,  with  no  ascertainable  connexion  with  even  the  slightest 
throat-affection,  to  convince  me  that  it  is  an  unjustifiable  closure  of 
inquiry  to  argue  back  to  a  hypothetical  diphtheria  as  the  necessary 
cause  of  all  such  affections ;  and  I  hold  this  opinion  in  the  face  of  the 
fact  that  there  are  many  slight  cases  of  diphtheria  with  indefinite  or 
undiscovered  signs  in  the  throat.  Except  in  the  case  of  recognised 
diphtheria  such  paralyses,  in  my  experience,  are  not  often  sequelae  of 
throat-affections,  but  either  are  apparently  idiopathic  or  follow  on 
measles,  enteric  fever  or  other  recognised  or  nondescript  febrile  attacks. 
Those  who  regard  this  group  of  affections  as  always  diphtheritic  are 
constrained  by  facts  to  admit  that  they  must  take  place  in  a  consider- 
able number  of  cases  after  not  only  the  mildest,  but  also  completely 
unrecognisable,  diphtheria ;  and  there  are  some  who  maintain  that  the 
frequency  of  the  paralysis  is  in  inverse  proportion  to  the  definiteness 
and  severity  of  the  causal  disease.  It  is  certainly  clear,  when  we  con- 
sider the  great  and  early  fatality  of  diphtheria,  that  the  paralysis  under 
notice  can  but  rarely  have  a  chance  of  existence  in  the  worst  cases ;  for, 
although  it  may  sometimes  take  place  very  early  in  the  disease,  it  is  far 
most  frequently  first  observed  in  the  second  or  third  week,  and  often 
much  later,  after  the  subsidence  of  the  acute  attack.  With  this  practical 
and,  as  I  believe,  clinically  important  comment  I  shall  shortly  describe 
the  paralyses  in  question  under  the  conventional  term  "  diphtheritic  ; " 


2  68  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

for  most  of  them,  if  not  a  large  majority,  occur  in  connexion  with 
undoubted  diphtheria. 

The  chief  mark  of  these  cases  is  a  varying  degree  and  extent  of  motor 
paralysis,  most  often  symmetrical  in  distribution,  slowly  spreading,  and 
often  tending  to  attack  fresh  parts  while  others  are  recovering.  Hyper- 
aesthesia  of  the  paralytic  parts  is  sometimes  noted  at  the  onset,  but  rarely 
in  children ;  and  some  degree  of  numbness  and  anaesthesia  is  present  in 
most  cases.  The  knee-jerks  are  mostly,  but  not  always,  absent,  faradic 
contractility  is  usually  lessened  or  abolished,  and  in  extensive  cases  of 
long  standing  the  reaction  of  degeneration  may  be  detected  by  the  test 
of  the  galvanic  current.  In  many  instances  that  I  have  observed,  the 
paralysis,  which  is  generally  incomplete,  is  accompanied  by  tremors  or 
movement  of  the  limbs  indistinguishable  from  those  of  insular  sclerosis. 
"With  certain  exceptions,  which  are  grave  and  often  fatal,  these  paralyses 
tend  almost  always  to  complete  recovery  in  the  course  of  weeks  or,  it 
may  be,  of  many  months. 

The  aetiology  of  these  paralyses  is  uncertain.  Changes  have  been 
found  post-mortem  in  several  cases  both  in  the  nerve-centres  and  the 
nerves,  but  in  others  these  structures  are  apparently  normal.  'No  definite 
cause  as  yet  suggested  covers  all  the  clinical  facts.  The  wisest  utter- 
ance on  the  subject  is,  I  think,  that  of  Bristowe,  who  says  that  "  on 
the  whole  it  seems  probable  that  a  wave,  so  to  speak,  of  slight  inflam- 
matory or  other  morbid  process  slowly  traverses  the  medulla  oblongata 
and  the  cord,  and  in  some  cases  also  the  nerves  in  relation  to  the 
paralysed  districts."  This  hypothesis  leaves  room  for  the  possibility  of 
some  action  on  the  nerves  of  the  absorbed  poison  of  diphtheria,  analogous 
to  that  of  other  nerve-poisons  which  may  modify  or  destroy  functions 
while  causing  no  demonstrable  change. 

Paralysis  of  the  soft  palate  is  by  far  the  most  frequent  form  of  the 
affection  which  can  be  demonstrated,  and  is  alone  observed  in  a  large 
number  of  cases;  but  a  notable  weakness  and  infrequency  of  pulse 
with  enfeebled  heart-sound,  pointing  to  disturbed  cardiac  innervation, 
is  a  very  common  accompaniment.  Sometimes,  though  not  very  often, 
there  is  more  extensive  paralysis  of  the  pharynx,  and  possibly  of  the 
oesophagus,  causing  much  dysphagia  and  the  necessity  of  nasal  feeding. 
In  such  cases  the  pharyngeal  mucosa  is  insensitive,  and,  the  upper  part 
of  the  larynx  being  sometimes  similarly  affected,  food  may  enter  the 
glottis  and  occasion  cough.  The  paralysis  of  the  palate  is  evidenced  by 
the  motionless  velum  and  pendulous  uvula,  nasal  voice,  snoring,  and  the 
return  through  the  nose  of  swallowed  fluids.  Faulty  accommodation 
from  paralysis  of  the  ciliary  muscles,  shown  especially  in  loss  of  near 
vision,  is  almost  as  frequent  as  the  palatal  weakness,  and  can  be  estab- 
lished in  a  large  number  of  cases  where  no  impairment  of  sight  is 


THE  PARALYSES  OF  CHILDHOOD.  269 

complained  of.     The   pupillary  light-reflex  is   maintained,  but  may  be 
sluggish.     These  three  phenomena, — the  palatal,  the  ciliary  and   the 
cardiac  weakness, — associated  as  a  rule  with  loss  of  the  knee-jerks,  are 
the  most  characteristic  marks  of  diphtheritic  paralysis,  and  are  in  my 
experience  mostly  preceded  by  recognisable  diphtheria.     The   further 
events  of  paralysis  of  the  limbs,  of  the  neck  and  trunk  muscles,  and 
of  the  respiratory  apparatus,  including  both  the  intercostals  and  the 
diaphragm,  are  seen  in  a  smaller  number  of  cases ;  and  it  is  in  this 
more  extensive  class  that  strabismus  of  all  kinds,  but  generally  double 
and    mostly   divergent,    and,    though    much    less    often,    ptosis,    facial 
paralysis,  and  affection  of  the  abductors  of  the  vocal  cords,  are  apt  to 
occur.     Although  any  or  almost  all  of  the  voluntary  muscles  may  suffer 
in  turn,  or  to  some  extent  simultaneously,  so  that  the  patient  may  be 
unable  to  move  or  raise  the  head,  the  paraplegic  distribution  (one  leg 
being  always  worse  than  the  other),  is  the  most  frequent ;  and  the  arms 
are  hardly  ever  alone  affected.     The  skin  over  the  weakened  parts  is 
usually  more  or  less  insensitive ;  and  in  some  cases  symmetrical  patches 
of  anaesthesia  may  be  observed  over  the  body,  especially  on  the  ex- 
tremities and  at  the  tip  of  the  nose.     Wasting  of  the  paralysed  muscles 
is  often  marked,  the  gait  may  be  ataxic  as  well  as  straddling,  and  the 
feet  tend  to  catch  the  ground.     Very  occasionally  there  is  impairment 
or  even  loss  of  control  over  the  bladder.     With  regard  to  the  knee- 
jerks  it  must  be  remembered  that,  although  usually  absent,  they  are 
sometimes  present ;  and  that,  while  their  absence  characterizes  a  large 
number  of  cases  of  diphtheria  without  discoverable  paralysis,  they  may 
occur  and  even  be  brisk  in  some  where  extensive  paralysis  supervenes. 
This  phenomenon  is,  therefore,  of  no  great  prognostic  value.     In  two 
cases  of  paraplegia  which  recovered,  one  with  left  ptosis,  and  the  other 
with  double  internal  strabismus,  but  without  any  history  of  previous 
diphtheria,  the  knee-jerks  were  present  throughout.     It  is  in  such  cases 
as  these,  however,  which  are  usually  classed  as  diphtheritic,  and  also  in 
others  where,  with  generally  absent  knee-jerks,  the  paralysis  is  mostly  or 
entirely  confined  to  the  limbs  and  trunk  muscles,  that  a  clear  history  or 
other  evidence  of  diphtheria  such  as  palatal,  ciliary  or  cardiac  paralysis 
is  very  often  wanting.     It  is  in  these  doubtful  cases,  too,  that  rhythmical 
tremors  and  ataxia  are  most  frequently  noted,  and  that  weakness  of  the 
legs  and  back  may  give  rise  to  a  gait  and  mode  of  rising  from  the  ground 
which  reminds  us  of  the  phenomena  of  pseudo-hypertrophic  paralysis. 
I  have  seen  several  cases  of  this  kind,  and  one  where  the  paralysis  was 
of  a  remarkably  shifting  or  metastatic  character  and  repeatedly  invaded 
both  facials  and  the  limbs  on  both  sides.     There  were  rhythmical  tremors 
and  variable  anaesthesia,  and  the  knee-jerks  were  present  throughout, 
sometimes  feeble  and  sometimes  exaggerated.     There  was  no  history  of 


270  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

any  throat-affection.  The  first  observed  symptom  was  nasal  speaking, 
and  recovery  did  not  take  place  for  nine  months.  In  most  instances 
of  unquestionable  diphtheritic  paralysis  there  is  albuminuria,  the  pre- 
sence of  which  may  assist  us  in  the  diagnosis  of  some  doubtful  cases. 

"With  the]  exception  of  cases  marked  by  great  slowing  or  by  much 
frequency  and  irregularity  of  the  heart's  action,  and  of  those  extensive 
paralyses  which  involve  the  intercostals  or  the  diaphragm,  ultimate 
recovery  may  almost  always  be  expected,  and  the  sooner  the  more  slight 
and  limited  the  paralysis.  Especially  should  we  be  on  our  guard  against 
the  more  serious  complications  when  one  part  after  another  is  succes- 
sively attacked.  Paralysis  limited  to  the  palate  or  to  the  eye  mostly 
recovers  in  a  few  weeks ;  but,  when  the  limbs  or  trunk  are  affected 
as  well,  months  may  pass  before  complete  recovery  of  any  part.  With 
intercostal  or  diaphragmatic  paralysis,  the  chief  marks  of  which  have 
been  mentioned  under  the  head  of  diphtheria,  the  danger  is  very  great ; 
some  cases  dying  quickly,  and  most  after  no  long  time,  with  pulmonary 
complications.  I  have  seen  pronounced  intercostal  paralysis  once,  and 
diaphragmatic  paralysis  three  times,  end  in  almost  sudden  death  after 
the  child  had  taken  a  few  short  gasps  for  breath.  In  such  cases  the 
pulse  is  usually  very  frequent,  and  death  is  the  immediate  result  of 
cardiac  failure.  It  is  well  in  practice  never  to  pronounce  a  definitely 
good  prognosis  until  all  signs  of  paralytic  nature  have  disappeared  for 
at  least  a  fortnight. 

In  the  treatment  of  all  cases  of  proved  or  suspected  diphtheritic 
paralysis  absolute  rest  in  bed  must  be  enjoined,  and  the  greatest  atten- 
tion given  to  nutrition.  When  there  is  pharyngeal  paralysis,  and  still 
more  when  the  oesophagus  and  the  larynx  are  involved,  food  must  be 
given  by  the  nasal  or  oesophageal  tube.  Alcoholic  stimulants  should 
be  frequently  taken,  and,  when  there  is  much  cardiac  weakness,  large 
quantities  may  be  necessary.  Strychnia  is  perhaps  useful,  but  should 
of  course  be  given  cautiously,  beginning  with  small  doses.  For  the 
limb  paralysis  a  daily  application  of  the  galvanic  current  of  just  suffi- 
cient strength  to  produce  response  may  at  times  be  ordered.  Artificial 
respiration,  three  or  four  times  a  day  for  a  quarter  of  an  hour,  is  strongly 
recommended  by  Dr.  Pasteur  in  all  cases  of  respiratory  paralysis, 
especially  of  the  diaphragm,  for  the  purpose  of  preventing  or  lessening 
the  collapse  and  other  pulmonary  troubles  which  so  frequently  occur. 
Paradism  of  the  chest  has  been  also  advocated  by  Duchenne  and  others. 
Iron  and  arsenic  may  be  given  systematically  in  all  cases. 


ACUTE  DISEASES  OF  THE  BRAIN.  2  J  I 


CHAPTER  III. 

ACUTE   DISEASES    OF  THE    BPvAIN. 

Certain  symptoms  of  disturbed  brain-function,  mainly  consisting  of 
spasm,  paralysis,  headache  and  affections  of  consciousness  accompanied 
by  varying  degrees  of  fever,  are  referable  to  involvement  of  the  surface 
of  the  brain  in  inflammation  of  the  pia  mater,  such  inflammation  being 
due  to  various  causes  and  either  of  primary  or  secondary  origin.  There 
is  sometimes  considerable  difficulty  at  the  outset  in  deciding  on  the  true 
cause  of  these  symptoms ;  for  results  at  first  sight  very  similar  may  follow 
on  the  temporary  brain  disturbance  from  that  modified  blood  supply, 
generally  hypercemic  or  toxsemic  in  character,  which  is  part  of  many 
febrile  diseases.  Of  these,  pneumonia  and  enteric  fever  may  be  quoted 
as  examples.  In  the  case  of  young  children  this  difficulty  is  frequent, 
and  has  an  important  bearing  both  on  prognosis  and  treatment. 

Great  irritability,  dislike  of  light,  convulsion  of  varying  degree,  vomit- 
ing, and  even  temporary  strabismus  and  contraction  of  the  pupils  may 
all  be  the  results  of  but  temporary  brain  disturbance  without  inflamma- 
tion; and,  although  it  is  generally  true  that  the  more  suddenly  such 
symptoms  arise  the  less  likely  is  their  primary  cerebral  origin,  I  am 
convinced  that  it  is  often  impossible  to  form,  and  rarely  wise  to  express, 
a  definite  opinion  at  the  outset  of  any  given  case.  I  have  seen  several 
instances  of  fatal  meningitis,  including  some  of  tubercular  origin,  which, 
at  least  clinically,  have  begun  suddenly  with  convulsions  and  high  fever. 
There  are  certain  symptoms  now  to  be  referred  to  which,  occurring  early, 
may  lessen  or  remove  doubt,  but  these  are  often  not  marked  till  later  \ 
and,  generally  speaking,  when  we  can  make  an  absolutely  positive  diag- 
nosis of  brain-disease,  the  case  is  already  too  far  advanced  for  pathology 
to  permit  of  other  than  a  grave  prognosis.  The  symptoms  pointing  either 
to  great  probability  or  approximate  certainty  of  acute  inflammation,  which, 
as  arising  most  often  from  the  membranes,  is  usually  described  as  menin- 
gitiSf  are  local  spasms  or  paralyses,  marked  inequality  or  inactivity  of  the 
pupils,  great  and  increasing  drowsiness,  unrhythmical  breathing,  especially 
when  interrupted  by  sighs  or  spells  of  "  Cheyne-Stokes "  respiration, 
and  distinct  irregularity  in  the  force,  frequency  and  rhythm  of  the  heart- 
beats. These  and  other  important  symptoms  occur,  some  or  all,  sooner 
or  later  in  the  course  of  acute  brain  mischief;  and  their  special  significance 
will  now  be  considered  in  relation  to  the  various  forms  of  meningitis. 
Of  acute  general  encephalitis  with  red  or  white  softening,  examples  of 


2/2  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

which,  though  rare,  are  occasionally  met  with,  I  need  say  nothing,  as  it 
has  neither  a  definitely  distinctive  symptomatology  nor  any  characteristics 
special  to  childhood.  "With  regard  to  localised  cerebral  abscess  I  would 
only  remark  that  it  is  not  very  common,  and  has  no  special  marks 
in  childhood.  Besides  resulting  from  hone-disease,  ear-mischief  and 
sometimes  broken-down  tumours,  abscess  in  the  brain  is  known  to  be 
occasionally  attributable  by  way  of  embolic  processes  to  suppuration  in 
the  lungs,  bronchi  or  pleura,  the  morbid  material  entering  the  left  heart 
by  the  pulmonary  veins. 

Acute  Meningitis. 

The  symptoms  of  meningitis  are  those  of  involvement  of  the  surface 
of  the  brain  and  are  signified  by  motor,  sensory  and  mental  changes.  In 
most  cases  in  childhood  this  affection  has  its  origin  in  the  pia  mater ;  and 
is  the  immediate  result  either  of  tubercle  starting  in  the  membrane  or 
in  the  brain  beneath,  or  of  some  other  less  certainly  differentiated  inflam- 
matory or  infective  processes,  among  which  it  is  customary  to  mention 
"  simple  meningitis."  In  others  definite  primary  lesions  are  found  out- 
side the  pia  mater,  such  as  disease  of  the  cranial  bones  and,  especially, 
otitis  media. 

There  are  certain  cases,  too,  in  which  some  symptoms  of  meningitis  or, 
more  strictly  speaking,  of  cerebral  trouble  are  seen,  and  nothing  is  found 
in  those  who  die  beyond  an  excess  of  fluid  in  the  cerebral  ventricles. 
Such  are,  however,  as  far  as  we  know,  most  probably  referable  to  an 
inflammatory  origin,  and  may  be  termed  subacute  hydrocephalus.  For 
clinical  purposes  certainly  they  will  best  be  considered  in  connexion 
with  meningitis.  I  shall  describe  first  the  tubercular  form  of  meningitis, 
not  only  as  the  most  frequent,  but  also  because  it  affords  the  widest  field 
for  a  detailed  study  of  symptoms  from  its  generally  more  gradual  onset 
and  slower  course. 

In  a  practical  work  confined  to  disease  in  children  it  is  unnecessary 
to  give  any  pathological  description  of  the  various  forms  of  meningitis, 
except  so  far  as  the  pia  mater  may  be  concerned;  and  I  will  only  say, 
with  regard  to  the  clinical  aspect  of  a  class  of  cases  which  are  due  to 
extra-cerebral  lesion,  and  where  the  inflammatory  effusion  is  primarily  in 
the  dura-arachnoid  cavity,  that  the  symptoms  are  often  at  first  those  of 
rigidity,  convulsion  and  pain,  which  may  continue  for  some  time  before 
coma  and  paralysis  set  in  as  evidence  of  more  profound  involvement  of 
the  brain.  Several  cases  in  my  note-books  of  purulent  meningitis  of  the 
convexity  of  the  brain,  following  on  definite  otitis,  illustrate  this  state- 
ment, which,  however,  is  far  from  being  universally  true. 

Tubercular  Meningitis. — I  have  no  doubt  from  my  experience  both 


ACUTE  DISEASES  OF  THE  BRAIN.  273 

in  children  and  adults  that  this  affection,  though  it  may  occur  at  any 
age,  is  hy  far  most  frequent  under  twelve  years.     I  have  seen  necropsies 
of  several  cases  of  one  year  and  under,  such  as  are  often  regarded  as 
very  rare,  owing,  probably,  to  the  small  number  of  hospitals  admitting 
babies   and   to    the  difficulty   of  obtaining   post-mortem    examinations 
in  private  practice.     A  considerable  minority  of  cases  have  no  family 
history  of  phthisis  or  other  tubercular  disease,  and  several  begin  suddenly 
with  cerebral  symptoms  in  the  midst  of  apparent  health.     The  well- 
known  premonitory  symptoms,  described  at  length  in  text-books  and 
monographs,  and  probably  referable  to  the  process  of  tubercle  elsewhere 
than  in  the  meninges,  doubtless  obtain  in  most  instances ;  but,  after  a 
review  of  over  one  hundred  carefully  noted  cases,  besides  many  others,  in 
my  hospital  books,  I  can  say  that  the  cerebral  symptoms  are  quite  as 
often  seemingly  primary  in  infants  as  in  older  children.     Post-mortem 
examination  shows  too  that  tuberculosis  elsewhere,  and  especially  lung- 
involvement,  is  as  much  marked  in  older  children  as  in  infants.     An 
hereditary  history  of  tuberculosis  and  premonitory  symptoms  are  how- 
ever, I  think,  but  seldom  both  lacking  in  the  youngest  patients,  though 
I  have  seen  a  boy  of  fifteen  months  who,  with  a  good  family  history, 
was  positively  stated  to  have  been  quite  well  till  the  day  after  a  severe 
fall,  and  after  a  short  course  of  the  illness  was  found  post-mortem  to  be 
the  subject  of  extensive  tuberculosis  affecting  many  organs  besides  the 
brain. 

I  mention  these  points  merely  to  discourage  the  undue  weight  often 
given  to  clinical  averages  in  the  diagnosis  of  individual  cases,  and  would 
emphasise  the  fact  that  in  nearly  all  cases  of  tubercular  meningitis  the 
presence  of  tubercle  elsewhere  is  proved  by  post-mortem  examination. 
In  very  many  of  my  cases  measles,  so  often  apparently  the  determining 
cause  of  tuberculosis,  preceded  the  onset  of  the  meningitis  by  a  few 
weeks,  the  children  having  ailed  during  the  interval ;  and  in  some  the 
affection  seemed  to  follow  directly  on  otitis.  We  must  not,  in  fact,  when 
making  our  diagnosis,  trouble  ourselves  much  more  about  the  origin  of  this 
special  affection  than  about  that  of  any  tuberculosis  at  any  age,  although 
doubt  may  very  frequently  be  lessened  or  perhaps  removed  by  marked 
evidence  of  family  phthisis,  by  a  definite  history  or  indication  of  previous 
brain  mischief  (which  may  be  due  to  tubercular  tumours),  or  by  the 
discovery  of  tubercular  processes  in  other  organs.  In  none  of  its  varieties, 
indeed,  does  tuberculosis  play  a  more  striking  clinical  part  as  a  specific 
disease  from  apparently  ah  extra  infection  than  in  some  cases  of  cerebral 
meningitis. 

It  follows  that,  in  the  absence  of  any  observable  local  causes  such  as 
ear-disease,  nose-disease,  traumatism,  and  of  any  conditions  such  as,  for 
instance,  the  epidemic  or  sporadic  form  of  "  cerebro-spinal  meningitis," 

S 


274  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

pneumonia,  erysipelas,  or  other  febrile  affections  out  of  which  a  non- 
tuber  cular  meningitis  is  known  to  arise,  we  may  always  more  or  less 
strongly  suspect  tuberculosis  as  the  cause  of  any  given  case  presenting 
the  appearance  of  meningitis.  "We  have  to  fall  back  for  a  more  definite 
diagnosis  upon  the  fact  of  tubercle  being  by  far  the  most  frequent  cause ; 
on  the  usually  more  sudden  onset  and  rapid  course  either  towards  death 
or,  sometimes,  recovery  in  other  forms  of  the  disease  hereafter  to  be  dis- 
cussed ;  and  on  the  prevalent  predominance  in  the  tubercular  variety  of 
signs  of  basic  inflammation,  such  as  marked  irregularity  of  pulse  and 
breathing,  and  local  paralyses  of  the  external  muscles  of  the  eye,  of  the 
face,  or  perhaps  of  a  limb,  or  of  one  side  of  the  body  including  the  tongue. 
Meningitis,  however,  mostly  vertical,  with  convulsions  and  excitement 
rapidly  passing  into  coma,  is  not  confined  to  the  non-tubercular  forms ; 
and  non-tubercular  basic  meningitis  is  certainly  sometimes  observed. 
Therefore,  however  sure  we  may  feel  of  the  presence  of  meningitis,  we 
are  rarely  quite  justified  in  giving  the  almost  hopeless  prognosis  which 
definite  diagnosis  of  the  tubercular  variety  entails;  and,  further,  since 
pathological  science  gives  some  reason  to  believe  that  even  a  tubercular 
case  may  at  least  temporarily  recover,  we  should  postpone  our  fatal  fore- 
cast until  well-marked  coma  and  paralysis  set  in. 

The  first  symptoms  of  tubercular  meningitis,  preceded  mostly  by  definite 
or  indefinite  illness  of  varying  duration  with  restlessness,  irritability,  and 
some  wasting,  are,  generally,  vomiting,  headache,  and  hyperaesthesia  with 
or  without  photophobia.     The  warning  hereby  given  is  strengthened  by 
the  presence  of  some  fever,  and  by  the  absence,  on  careful  and  exhaustive 
examination,  of  any  evidence  of  pneumonia  or  signs  of  acute  local  or 
general  disease  other  than  what  might  be  referable  to  tubercular  growths 
in  brain,  thorax,  abdomen  or  elsewhere.     More  definite  cerebral  symptoms 
soon  arise ;  and,  if  we  desire  to  describe  the  affection  by  stages,  it  may  be 
said  that  convulsions,  sometimes  often  repeated,  an  irregular  and  most 
often  frequent,  though  sometimes  very  infrequent,  pulse,  irregular  breath- 
ing accompanied  by  a  tendency  to  sigh,  somewhat  contracted  and  often 
unequal  pupils  and  great  irritability  to  sound  or  movement  may  precede, 
for  several  days  or  a  week  or  two,  the  signs  of  profound  impairment  of 
brain-function  which   mark  the  remaining  course  of  the  disease  and 
increase  until  the  end.     Such  are  various  paralyses,  inharmonious  move- 
ment of  the  eyes,  drowsiness  going  on  to  coma,  dilated  and  inactive 
pupils,  and,  perhaps,  an  infrequent  pulse  becoming  generally  much  more 
frequent  again  before  death.     But  the  more  I  see  of  meningitis  and  re- 
read the  notes  of  my  many  cases,  the  less  practical  value  I  place  on  any 
division  of  symptoms  into  orderly  stages ;  for,  apart  from  the  innumerable 
exceptions  to  even  such  a  general   succession  of  symptoms  as  above 
sketched,  and  the  frequently  early  appearance  of  paralytic  phenomena, 


ACUTE  DISEASES  OF  THE  BRAIN.  275 

we  must  take  into  account  the  remarkable  and  well-known  fact,  which 
my  own  cases  amply  illustrate,  of  the  complete  disappearance  of  many  or, 
perhaps,  most  of  the  symptoms  at  even  a  very  late  period.  Among  other 
very  striking  examples  of  this  I  have  notes  of  a  child  four  years  old 
who  had  had  typical  symptoms,  and  was  for  six  days  unconscious  of 
her  surroundings  and  irresponsive  to  all  stimuli  of  touch,  light  and 
sound,  but  suddenly  woke  up  for  a  period  of  four  hours,  moving  her 
limbs  and  audibly  asking  to  see  her  mother,  and  died  in  coma  about 
two  hours  afterwards.  I  shall  therefore  refer  seriatim  to  the  various 
symptoms  seen  in  tubercular  meningitis,  noting  their  diagnostic  signifi- 
cance and  usual  clinical  position,  and  remarking,  by  the  way,  that  none 
absolutely  differentiate  it  from  non-tubercular  affections. 

Vomiting  occurs  at  the  onset  in  most  cases,  and  may  last  for  several 
days.  It  is  rarely,  if  ever,  absent  in  the  ordinary  form  of  basilar  menin- 
gitis. When  primary  gastric  disturbance  can  be  with  probability  ex- 
cluded, and  there  is  no  diarrhoea,  or  still  more  when  there  is  constipation, 
this  should  always  be  regarded  as  a  possibly  grave  symptom.  Headache, 
with  some  photophobia  as  a  rule,  either  complained  of  or  inferred  from  the 
child's  appearance  or  actions,  is  probably  of  almost  universal  occurrence ; 
when  persistent,  it  adds  much  to  the  probability  of  the  cerebral  signifi- 
cance of  vomiting,  and,  in  cases  where  its  existence  is  certain,  it  is  one 
of  the  most  important  facts  in  early  diagnosis.  Of  these  two  symptoms, 
vomiting  usually  ceases  early  in  the  disease,  although  it  sometimes  per- 
sists ;  while  headache  most  often  seems  to  last  until  signs  of  coma  appear. 
There  is  nothing  very  characteristic  in  the  nature  of  the  vomiting  itself, 
which  may  indeed  take  place,  as  I  have  frequently  noticed,  only  after 
swallowing  food  or  drink.  The  headache  is  often  frontal,  but  more 
frequently  quite  general.  The  oft-quoted  distinction  between  cerebral 
and  gastric  vomiting  on  the  ground  of  the  former  being  sudden  or  "pro- 
jectile" and  unattended  by  nausea  is,  in  my  opinion,  of  no  great  value, 
especially  in  young  infants.  When  the  time  has  passed  for  the  appear- 
ance of  characteristic  eruptions  in  the  exanthemata,  and  pneumonia  has 
been  excluded  as  far  as  possible,  any  suspicion  of  enteric  fever,  which 
often  begins  with  severe  headache  and  vomiting,  is  much  lessened  by 
the  presence  of  one  or  more  of  the  following  symptoms  which  are  more 
or  less  distinctive. 

Irregularity  of  the  pulse  and  breathing,  and  especially  of  the  latter, 
are  valuable  diagnostic  signs.  Irregular  breathing,  accompanied  by 
marked  sighing,  or  by  periods  of  more  or  less  marked  Cheyne-Stokes 
respiration,  persists  as  a  rule  to  the  end,  the  pulse,  however,  varying 
much  both  as  regards  irregularity  and  frequency,  and  always  becoming 
regular  in  proportion  to  increase  in  rate.  In  the  early  stages  of  tuber- 
cular meningitis,  especially  in  infants,  these  signs  may  be  absent  or  at 


276  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

least  occur  only  in  spells.     Infrequency  of  pulse,  often  a  valuable  indi- 
cation of  primary  brain  mischief  in  febrile  conditions  of  adults,  is,  in 
my  experience,  but  rarely  observed  early  in  the  meningitis  of  young 
children,  the  majority  of  my  cases  showing  either  acceleration  through- 
out, or  only  a  late  slowing,  followed  usually  by  much  increased  rate  before 
death.      Constipation  is  the  general  rule,  and  is  mostly  accompanied  by 
a  retraction  of  the  abdominal  icalls  which,  after  a  while,  may  become 
extreme,  and  give  rise  to  the  well-known  "boat-shaped"  belly.     In  a 
considerable  minority  of  cases,  however,  there  are  loose  motions  or  diar- 
rhoea, the  abdomen  being  then  almost  always  either  of  normal  appear- 
ance or  distended.      Inelasticity  of  the  shin  of  the  abdomen,  with  a 
distinct  feeling  of  doughiness  on  palpation,  is  unquestionably  very  fre- 
quent, especially  in  the  later  periods  of  the  disease ;  but  it  is  in  no  way 
confined  to  tubercular  or  even  to  cerebral  cases,  being  fairly  often  seen 
in  an  extreme  degree  in  alimentary  disorder  with  much  wasting,  and 
especially  in  enteric  fever.      I  have  long  believed,  from  clinical  and 
post-mortem  experience,  that  all  abdominal  signs  and  symptoms  other 
than  the  prevalent  constipation  and  retraction  are  mainly  dependent  on 
the  abdominal  tuberculosis  which  so  frequently  precedes  and  increases 
with   the   meningitis.      Tubercular   meningitis  is  extremely  often  the 
last   event   of    general    tuberculosis ;    and   it   is    mainly   in   the   non- 
cerebral  symptoms  and  in  the  history  and  course  of  individual  cases 
that  we  must  search  for  the  diagnostic  points  which  distinguish  the 
tubercular  from  other  forms  of  meningitis.     Cervical  opisthotonos  is  not 
infrequently  seen,  but  it  is  usually  somewhat  late  in  appearance  and 
referable  either  to  considerable  ventricular  effusion  or  to  meningitis  of 
the  cervical  cord.     As  an  early  symptom  it  rather  points  to  a  non- 
tubercular  meningitis,  and  especially  to  the  cerebro-spinal  form.     Nys- 
tagmus is  very  frequent  in  the  later  stages  of  the  disease,  but  has  no 
special  diagnostic  significance  ■  and  the  same  may  be  said  of  grinding 
of  the   teeth  which   often   occurs   quite   early.       Convulsion   is  by  no 
means  rare   even  as   an  initial   symptom,  but  is   not  distinctive  even 
of   cerebral  disease   unless  definitely  one-sided,  and  not  always   then. 
When  frequently  repeated,  as  it  not  seldom  is,  until  coma  sets  in,  it 
often  points  to  an  involvement  of  the  convexity.     Rigidity  of  limbs 
of  varying  degree  and  duration  is  frequently  observed.     Paralyses  of 
the  cranial  motor  nerves,  especially  of  the  sixth  and  less  often  of  the 
seventh,  are  valuable  signs  of  basic  meningitis,  and,  therefore,  most  often 
of  the  tubercular  form  ■  as  also  is  definite  hemiplegia,  which  may  be  due 
to  softening  of  the  brain  ganglia  so  often  seen  post-mortem  in  connexion 
with  softening  of  the  commissures  and  intra-ventricular  effusion.     The 
paralyses  in  tubercular  meningitis  are  often  varying  and  evanescent  in 
character.     More  or  less  rhythmical  or  repeated  similar  movements  of  arms 


ACUTE  DISEASES  OF  THE  BRAIN.  277 

or  legs  are  of  very  frequent  occurrence  in  meningitis,  occurring  generally 
in  the  later  stages  with  increasing  drowsiness.  These  movements  are 
not  of  convulsive  character,  but  are,  in  appearance  at  least,  voluntary  or 
the  result  of  some  feeling  of  irritation,  and  may  continue  for  hours 
together.  Bright  and  long-continued  flushing  of  the  face  and  other  parts 
of  the  body,  or  "  tache  cerebrale,"  either  on  movement  only,  or  following 
light  touches  with  the  finger,  or  sometimes  permanent  with  fluctuations 
in  degree,  is  often  seen,  and  is  usually  a  sign  of  advanced  disease,  as  also 
is  the  mucoid  film  on  the  conjunctivae  so  frequently  seen  to  a  marked 
extent  shortly  before  death.  Even  a  slight  amount  of  this  flushing  at 
the  outset  or  quite  early  in  the  disease  may  increase  already-formed 
suspicions  of  meningitis,  but  I  have  many  times  seen  it  well-marked 
in  fevers,  and  cannot  regard  it  as  such  an  important  aid  to  diagnosis 
as  I  once  was  inclined  to  do. 

The  temperature  is  raised  more  or  less  throughout  in  most  cases, 
ranging  as  a  rule  between  ioo°  and  102°  or  1030;  it  is  subject  to  great 
variations  in  the  same  and  different  cases ;  but,  generally  speaking,  it 
ranges  higher  in  infancy  than  in  later  childhood.  Although  it  may 
sometimes  be  normal  or  even  markedly  subnormal  before  death,  my 
experience  is  that  a  great  rise  at  the  end,  often  as  high  as  1060  or  1070 
and  sometimes  higher,  is  very  much  more  frequent,  even  in  cases  which 
have  previously  had  a  low  febrile  register. 

The  state  of  the  pupils  in  the  early  stage  is  often  not  characteristic. 
They  are,  perhaps,  mostly  unequal  in  some  degree,  often  contracted  when 
the  patient  is  irritable  or  in  the  early  convulsive  stage,  and  almost  always 
dilated  and  immobile  later  on.  Marked  inequality  of  pupils  is  doubtless 
a  valuable  positive  symptom  of  brain  mischief,  but  I  have  several  times 
observed  continuous  equality  even  in  severe  cases. 

Hyperesthesia,  including  photophobia,  is  a  very  marked  symptom  in 
most  cases  even  in  the  earliest  stages,  and  may  last  for  many  days. 
Movement  is  resisted,  often  with  screaming,  and  in  a  few  cases  and  most 
often  at  night  the  so-called  "hydrocephalic  cry"  is  suddenly  heard.  I 
am  not  sure  whether  this  may  not  be  referable  to  terror  as  well  as  pain, 
night  terrors  with  hallucinations  and  very  often  with  screaming  being 
frequent  in  the  notes  of  the  older  cases,  and  occurring  quite  early  in  the 
disease.  Sudden  crying  out,  too,  is  sometimes  referred  by  the  sufferer  to 
pain  in  the  epigastrium,  but  the  pain  is,  I  think,  more  frequent  in  the 
cerebro-spinal  form  of  meningitis  presently  to  be  mentioned,  and  may 
then  perhaps  be  referred  to  involvement  of  the  roots  of  the  spinal  nerves. 
Anaesthesia,  on  the  other  hand,  increasing  in  degree  is  the  rule  in  the  later 
stages,  and  may  sometimes  be  observed  quite  early  when  the  disease  is 
rapidly  advancing.  The  conjunctiva  may  be  comparatively  insensible 
before  the  poAver  of  speech  and   spontaneous  movement   has  ceased. 


278  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

Delirium  of  any  extent  or  duration  is  certainly  not  often  seen  in  the 
meningitis  of  children,  and  is  perhaps  only  compatible  with  an  inchoate 
lesion.  The  mental  as  well  as  the  physical  symptoms  of  meningitis  are 
those  of  progressive  impairment  and  loss  of  function. 

I  have  often  seen  profuse  and  continued  sweating  in  tubercular 
meningitis  :  and  in  a  very  few  cases,  but  in  none  with  constipation  or 
abdominal  retraction,  rose-spots,  indistinguishable  from  those  of  enteric 
fever,  appear. 

The  longest  duration  noted  among  my  cases  with  necropsies  is  a  little 
over  four  weeks  from  the  first  observed  cerebral  symptoms,  but  the 
disease  may  sometimes  last  considerably  longer.  One  case  which  ran  a 
course  of  fifty-three  days,  with  otherwise  typical  symptoms  and  a  history 
of  previously  failing  health,  was  found  post-mortem  to  be  non-tubercular. 
The  average  duration  of  the  cases  which  appear  clinically  to  be  most 
uncomplicated  is  probably  about  three  weeks.  There  is  nearly  always 
marked  wasting.  Convulsions  very  often  immediately  precede  death, 
whether  or  no  they  may  have  been  observed  earlier.  The  younger 
the  patient  the  shorter,  as  a  rule,  is  the  course  of  the  disease.  The 
meningitic  symptoms  may  be  greatly  masked  or  almost  entirely  obscured 
by  those  of  more  general  disease,  especially  in  cases  of  abdominal  or 
pulmonary  tuberculosis,  and  when  there  has  been  much  wasting  and 
exhaustion.  In  some  indeed  I  have  seen  no  symptoms,  besides  irrita- 
bility and  drowsiness,  •which  could  with  any  reason  be  referred  to  cere- 
bral mischief.  A  remarkable  case  in  illustration  of  this  is  reported  by 
Dr.  Sturges  in  vol.  i.  of  the  Westminster  Hospital  Reports.  Occasionally 
there  is  a  temporary  initial  stage  of  wild  excitement  or  acute  mania 
which  may  last  for  some  days.  This  is  seen  mostly  in  older  children  and 
adults ;  and  may  obscure  the  diagnosis  to  even  a  practised  observer. 

Tubercular  meningitis  supervening  on  tubercular  tumours  in  the  brain, 
or,  more  often,  on  peritonitis  or  extensive  tubercular  disease  in  the  lungs, 
usually  runs  a  very  rapid  course,  as  exemplified  by  many  of  my  cases. 

The  varying  and  special  symptoms  of  tubercular  meningitis  are  in 
some  degree  connected  with  the  amount  of  intra-ventricular  effusion,  and 
with  the  extent  and  locality  of  the  deposit  of  tubercle  and  its  accom- 
panying meningitis.  In  some  cases  unconsciousness  is  observed  almost 
from  the  first,  and  the  earlier  symptoms  above  enumerated  may  be 
altogether  wanting.  The  early  appearance  and  prominence  of  general 
paralysis  and  coma  are  sometimes  due  to  large  and  rapid  ventricular 
effusion. 

The  best  reasons  for  diagnosing  tubercular  meningitis  during  life  are 
a  history  of  family  predisposition  to  tubercle,  the  discovery  of  tubercular 
disease  elsewhere,  a  period  of  premonitory  symptoms,  local  evidence  of 
disturbance  at  the  base  of  the  brain,  a  gradual  course  of  the  disease,  and 


ACUTE  DISEASES  OF  THE  BRAIN.  279 

an  absence  of  any  more  demonstrable  origin.  There  is  one  sign  how- 
ever— the  presence  of  miliary  tubercle  in  the  choroid — which,  were  it  of 
more  frequent  occurrence  and  less  often  mistaken,  even  by  experts,  -would 
be  diagnostically  very  valuable ;  but  it  is  not  often  discovered,  except  in 
cases  of  clearly  general  tuberculosis,  and  has  not  seldom  been  suspected 
during  life  and  disproved  by  examination  of  the  fundi  after  death. 
Moreover  ophthalmoscopic  examination  is  very  difficult  with  meningitic 
children  before  the  paralytic  stage  of  the  disease,  when  the  diagnosis  is 
usually  certain.     JN"euro-retinitis  in  varying  degrees  is  most  often  present. 

The  morbid  anatomy  of  tubercular  meningitis  does  not  show  constant 
variations  explanatory  of  the  many  different  clinical  forms  of  the  disease. 
We  may,  however,  often  correctly  diagnose  the  somewhat  exceptional 
occurrence  of  much  lymph  on  the  surface  of  the  hemispheres  from  a 
rapid  clinical  course,  with  convulsions  and  rigidity  passing  into  coma, 
in  cases  apparently  uncomplicated  with  much  disease  elsewhere.  In  a 
large  majority  of  instances  different  degrees  of  effusion  of  lymph  or  pus 
at  the  base  of  the  brain  are  found,  with  miliary  tuberculosis  of  the  pia 
mater  of  very  various  extent.  The  tubercles  usually  follow  the  course 
of  vessels  and  are  most  especially  abundant  in  the  Sylvian  fissures,  in 
the  choroid  plexuses,  and  often  on  the  inner  surface  of  the  hemispheres. 
We  may  find  much  lymph  with  but  few  tubercles,  as  well  as  numerous 
tubercles,  especially  on  the  convexity  of  the  brain,  with  little  or  no 
lymph.  Masses  of  yellow  or  caseous  tubercle  are  not  seldom  seen,  and 
may  be,  especially  when  just  under  the  pia  mater,  the  starting-point 
of  the  meningitis.  Initial  convulsions,  especially  when  unattended  by 
marked  paralytic  symptoms  or  subsequently  impaired  consciousness,  and 
when  of  unilateral  distribution,  are  certainly  sometimes  referable  to  such 
tumours  localised  in  the  cortex.  I  have  either  seen  or  obtained  the 
history  of  such  convulsive  attacks  in  several  cases  which  at  different 
periods  subsequently  developed  meningitis. 

There  is  nearly  always  some,  and  often  very  large,  effusion  into  the 
ventricles ;  and  the  surrounding  brain  structures,  including  the  basic 
ganglia,  are  very  frequently  much  softened  or  quite  diffluent.  In  a  few 
cases  I  have  seen  the  signs  of  basilar  meningitis  with  no  visible  tubercles 
except  in  organs  other  than  the  brain.  Such  cases  are  rightly  regarded 
as  tubercular,  and  it  is  a  fact  that  without  microscopical  observation 
slight  miliary  tuberculosis  of  the  pia  mater  is  often  overlooked.  It  may 
indeed  sometimes  be  felt,  as  granular  matter,  where  it  cannot  be  seen 
by  the  naked  eye.  The  pia  mater  in  the  upper  part  of  the  cord  is  not 
very  rarely  found  to  be  the  seat  of  inflammatory  effusion  and  of  tubercle. 
In  some  few  cases  with  this  post-mortem  phenomenon  there  had  been 
marked  and  rigid  retraction  of  the  head.  Purulent  collections  in  both 
middle  ears  are  often  found,  as  also  in  cases  of  non-tubercular  meningitis, 


2  80  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

without  any  disease  of  the  bone  or  of  the  dura  mater.  Tuberculosis,  both 
miliary  and  caseous,  of  the  bronchial,  mesenteric  and  other  glands,  is  of 
exceedingly  frequent  occurrence,  and  we  very  often  find  these  processes 
in  the  lungs,  pleurae,  peritoneum,  liver,  spleen,  kidneys  and  other  organs. 
In  some  cases  extensive  tubercular  peritonitis  or  ulceration  of  the  in- 
testinal mucosa  explains  many  symptoms  observed  in  life.  A  careful 
examination  will  almost  always  discover  at  least  some  small  amount  of 
caseation  in  gland  or  other  organ.  I  have  never  seen  a  case  myself, 
although  instances  undoubtedly  occur,  of  tuberculosis  strictly  limited  to 
the  pia  mater. 

Of  the  ultimate  cetiology  of  this  disease  there  is  but  little  to  say, 
the  modern  theory  of  bacillary  infection  of  a  presumably  ready  subject 
covering  meningeal  as  well  as  other  tuberculosis.  It  may,  however,  at 
least  be  suggested  that  in  the  frequent  apparently  primary  forms  of 
meningitis,  with  but  little  disease  elsewhere,  the  rapidly  developing  brain 
and  richly  vascular  pia  mater  of  the  growing  child  are  especially  obnoxious 
to  the  tubercular  poison.  I  am  sure  that  measles  in  some  way  greatly 
encourages  tuberculosis,  whether  the  caseous  changes  so  frequently  found 
after  this  disease  are  themselves  tubercular  in  essence,  or  only  the  nidus 
of  a  subsequent  infective  material.  It  is  with  some  hesitation  that 
I  express  an  opinion,  not  unsupported  by  authority  but  resting  on  no 
demonstrable  basis,  that  in  some  instances  constant  and  excessive  mental 
application,  leading  to  hypersemia  of  brain,  may  be  the  determining  or 
at  least  an  important  contributory  cause  of  tubercular  meningitis.  The 
hypothesis  is,  at  the  worst,  reasonable,  and  from  certain  cases  I  have 
seen  I  cannot  but  consider  it  probable.  Severe  falls  and  blows  on  the 
head  may  also  be  regarded  as  possibly  exciting  causes. 

I  shall  reserve  the  subject  of  treatment  until  I  have  spoken  of  the 
remaining  forms  of  meningitis  in  childhood,  and  can  add  nothing  to  what 
I  have  incidentally  said  on  the  matter  of  prognosis  except  the  statement 
that  tubercular  meningitis  is  and  must  be  almost  always  fatal,  not  because 
of  the  mere  presence  of  tubercle,  but  because  tuberculosis,  being  essentially 
progressive,  has  likewise  progressive  effects. 

Meningitis  unconnected  with  tubercle,  but  with  symptoms  often  in- 
distinguishable from  those  of  the  tubercular  form,  not  seldom  occurs  in 
children.  It  is  sometimes  apparently  idiopathic ;  sometimes  closely  con- 
nected with  various  morbid  processes  such  as,  for  instance,  pneumonia, 
erysipelas,  ulcerative  endocarditis,  the  exanthemata,  "  cerebro  -  spinal 
fever,"  exposure  to  heat,  syphilis,  and  perhaps  rheumatism ;  and  some- 
times clearly  secondary  to  certain  cranial  lesions,  morbid  or  traumatic, 
of  which  purulent  otitis  is  the  chief.  After  reviewing  all  my  many 
noted  cases  of  meningitis  in  children  which  were,  either  most  pro- 
bably or  certainly,  unconnected  with  tuberculosis,  I  cannot  find   any 


ACUTE  DISEASES  OF  THE  BRAIN.  28  I 

grounds,  either  clinical  or  anatomical,  for  making  any  clear  or  practical 
division  between  them,  and  shall  therefore  but  shortly  mention  the 
main  groups.  Generally  speaking,  non-tubercular  meningitis  begins 
more  suddenly,  runs  a  shorter  though  sometimes  a  very  much  longer 
course,  tends  oftener  to  at  least  partial  recovery,  is  much  more  seldom 
only  basic  in  position,  more  frequently  involves  the  convexity  of  the 
brain,  and  is  less  rarely  purulent  in  character  than  the  tubercular  form 
already  considered.  With  the  exception,  perhaps,  of  those  cases  which 
are  either  traumatic  in  origin  or  clearly  secondary  to  disease  of  the 
petrous  bone  resulting  from  otitis,  we  must  recognise  in  all  these  (in- 
cluding probably  many  where  purulent  otitis  media  is  found  without 
carious  bone)  a  distinct  vulnerability  and  proneness  to  variously  caused 
inflammation  of  the  highly  vascular  pia  mater  which  invests  the  rapidly 
developing  brain  of  early  childhood.  It  is  remarkable  that  an  enormous 
majority  of  the  subjects  of  the  epidemic  form  of  cerebro-spinal  meningitis, 
so  little  known  or  at  least  so  seldom  described  in  England,  are  young 
children ;  and  it  is  not  improbable  that  very  many  cases  of  so-called 
idiopathic  meningitis,  as  well  as  those  which  occur  in  connexion  with 
pneumonia  and  other  acute  diseases,  are  due  to  specific  infection  especi- 
ally attacking  the  cerebral  membrane.  Practically,  in  a  large  number  of 
cases  of  meningitis  in  infants  where  there  is  absolutely  no  symptom  or 
discovery  of  tuberculosis  anywhere  in  the  body,  Ave  are  obliged  to  forego 
a  causal  diagnosis,  although  several  may  be  with  great  probability  referred 
to  one  or  other  of  the  sources  above-mentioned,  examples  of  many  of 
which  I  have  seen  myself. 

Of  apparently  idiopathic  meningitis,  clinically  uncomplicated  and 
without  any  other  post-mortem  lesion,  I  have  seen  several  instances ; 
and  some  cases  seemingly  of  this  nature  have  completely  or  partially 
recovered.  That  partial  recovery,  for  a  time  at  least,  can  take  place  is 
fairly  evidenced ;  first,  by  cases  with  marked  symptoms  which  get  well 
and,  dying  after  some  time  from  a  similar  or  quite  different  affection, 
show  post-mortem  evidence  of  old  meningeal  inflammation ;  and,  second, 
by  the  profound  mental  deterioration,  indicative  of  serious  brain  lesion, 
so  often  observed  after  recovery  from  most  of  the  physical  symptoms 
of  acute  meningitis.  In  these  partially  recovered  cases  the  special 
senses,  such  as  sight  and  hearing,  are  often  much  impaired  or  destroyed. 
It  remains  probably  true,  however,  that  only  a  very  limited  and  short- 
lived meningitis  can  miss  a  fatal  result ;  and  many  reported  cases  of 
recovery  are  due  to  the  still  wide-spread  error  of  lightly  diagnosing 
meningitis  from  "almost  any  marked  cerebral  symptoms  accompanied  by 
fever.  Many  indeed  of  the  early  symptoms  in  all  cases  of  meningitis 
are  doubtless  due  to  the  initial  and  acute  hyperemia  alone. 

Cases  symptomatically  identical  with  many  of  those  known  as  epidemic 


282  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

cerebrospinal  meningitis  or  cerebro-spinal^fever,  especially  of  the  non- 
eruptive  form,  are  unquestionably  of  no  rare  occurrence,  and,  like 
the  epidemic  cases,  not  seldom  recover.  It  may  possibly  be  better  to 
regard  these  as  sporadic  examples  of  the  epidemic  type-disease  than  to 
refer  them  to  the  unsatisfactory  class  of  "  idiopathic  cases,"  but  their 
setiology  is  at  the  best  hypothetical.1  In  addition  to  the  symptoms  of 
cerebral  meningitis,  usually  of  the  base,  there  is  marked  cervical  and 
often  dorsal  opisthotonos,  and  much  pain  in  the  body  and  limbs,  especi- 
ally increased  by  any  kind  of  movement.  Post-mortem  there  is  found 
cerebral  meningitis,  often  purulent  and  mostly  at  the  base,  and  much 
involvement  of  the  pia  mater  of  the  cord.  The  onset  of  the  illness  is 
more  or  less  sudden,  with  vomiting,  headache  and  often  varying  degrees 
of  delirium,  and  the  temperature  averages  somewhat  higher  than  in 
tubercular  meningitis.  The  duration  of  the  affection  is  very  variable, 
sometimes  of  many  weeks.  The  cases  which  recover  perfectly  are 
usually,  however,  of  shorter  febrile  course,  though  convalescence  may 
be  protracted.  Most  of  the  cases  which  we  meet  with  are  parallel  to 
those  of  the  epidemic  form,  where  the  brain  is  more  affected  than  the 
cord,  and  tonic  contractions  of  the  extremities,  though  frequently  present, 
are  not  very  prominent.  Lung  consolidations  occur  sometimes,  and  in 
one  well-marked  case  I  observed  a  copious  eruption  of  small  red  spots, 
especially  marked  on  the  chest  and  back,  appearing  after  admission  and 
lasting  until  death.  Of  the  epidemic  disease,  well-known  in  America 
and  Ireland  and  described  in  the  text-books,  I  shall  say  nothing,  for 
want  of  personal  knowledge ;  but  it  has  been  undoubtedly  recognised 
from  time  to  time  in  Great  Britain. 

Purulent  meningitis  is  but  an  extreme  form  of  what  we  have  con- 
sidered under  other  headings,  and  may  occur  in  any  form  of  the  disease. 
The  term  is  mostly  used,  however,  to  signify  the  cases  which  are  secondary 
to  disease  of  the  petrous  bone  or  some  other  lesion  in  the  cranial  cavity. 
It  is  found  both  at  the  base  alone  and  also  extending  over  the  convexity 
of  the  brain.  I  refer  hereafter  to  otitis  and  its  clinical  bearings,  and 
would  only  remark  here  that  it  is  at  least  probable,  from  some  cases 
that  are  apparently  meningitic,  that  a  limited  meningitis  of  a  non- 
suppurative character  may  be  set  up  by  otitis.  We  should,  then, 
examine  the  ears  and  also  the  nose  in  every  case  where  meningitis  is 
suspected. 

All  these  forms  of  meningitis  may  occur,  as  the  tubercular  variety 
does  sometimes,  with  very  slightly  marked  symptoms  or  perhaps  none 
at  all.     This  symptomatic  latency  however  is  almost 'entirely  confined 

1  Since  writing  the  above  I  have  read  an  article  on  Cerebro-spinal  Meningitis  in 
Brain,  Part  LVII.  1892,  by  Dr.  E.  F.  Trevelyan,  which  strongly  corroborates  this 
view  and  much  amplifies  its  grounds. 


ACUTE  DISEASES  OF  THE  BRAIN.  283 

to   children  who  are  the    subjects   of   previous   severe  disease  or  are 
markedly  depressed  and  wasted. 

Simple  Acute  Hydrocephalus. — Under  this  unsatisfactory  and  pro- 
bably imperfect  title  I  include  a  group  of  cases  which,  though  not 
frequent,  are  by  no  means  rare.  They  are  marked  by  symptoms  of 
cerebral  disturbance,  probably  sometimes  recover,  and  are]  shown,  in 
those  who  die,  to  be  connected  with  an  effusion  into  the  ventricles  with 
no  other  evidence  whatever  of  the  process  or  products  of  inflammation. 
The  symptoms,  briefly  speaking,  are  some  fever  with  sickness  and  often 
constipation,  followed  soon  by  pain  in  the  head  which  is  not  necessarily 
severe  nor  accompanied  by  photophobia ;  the  child  may  be  irritable,  but 
is  more  often  drowsy  though  easily  roused,  and  may  continue  to  feed 
well  and  even  talk  spontaneously.  This  condition  may  last  for  days, 
without  any  flushing,  disturbance  of  pulse  or  breathing,  convulsion, 
pupillary  signs,  or  other  symptoms  characteristic  of  more  than  passing 
disorder  of  brain.  But  drowsiness  most  often  increases  to  coma,  and 
before  death  there  are  sometimes  strabismus,  convulsion,  irregular  breath- 
ing, and  other  symptoms  usually  seen  in  the  final  stage  of  meningitis. 
The  complete  absence  for  even  many  days  of  any  localising  signs,  and 
especially  those  of  the  ordinary  basic  effusions,  the  undisturbed  intellect, 
and  the  redetermined  and  often  mild  character  of  the  symptoms,  which 
rightly  lead  us  to  exclude  meningitis  as  generally  understood,  may  also 
mislead  us  to  regard  the  cerebral  phenomena  as  temporary,  and  symp- 
tomatic of  some  general  or  local  disorder  which  may  have  eluded 
observation.  I  have  seen  such  cases  referred  to  dietetic  causes  or  to 
"  gastric  catarrh,"  and,  in  those  which  recover  before  any  marked  signs 
of  intra-cranial  pressure  have  set  in,  it  is  as  impossible  to  disprove  such 
a  fanciful  diagnosis  as  to  establish  the  presence  of  ventricular  effusion. 
But  many,  if  not  most,  of  the  cases  I  allude  to  end  in  death,  and  I 
know  of  no  certain  sign  by  which  we  can  avoid  a  great  risk  of  error  in 
giving  a  favourable  prognosis.  If  we  are  fairly  certain  of  the  absence 
of  other  disease  in  a  previously  healthy  child,  and  the  symptoms  of 
listlessness  continue  for  some  days  with  any  headache  or  fever,  however 
slight,  and,  still  more,  if  a  yet  open  fontanelle  distinctly  bidges,  we  must 
be  well  on  our  guard,  and  increasing  lethargy  will  soon  justify  a  very 
grave  prognosis.  Many  more  mistakes  are  made  on  the  optimistic  than 
on  the  pessimistic  side  in  cases  such  as  these,  even  by  practised  observers 
who  are  well  aware  of  their  pathological  entity.  Children  under  two 
years  of  age  are  most  often  the  subjects  of  this  affection,  but  I  have 
seen  cases  over  three.  It  is  more  than  likely  that  many  cases  of  the 
familiar  chronic  hydrocephalus  are  the  results  of  the  acute  affection 
above  described. 

At  the  close  of  this  review  of  acute  affections  of  the  cerebral  mem- 


284  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

branes  and  closely  allied  conditions,  it  is  well,  for  practical  reasons  of 
diagnosis,  to  refer  very  briefly  to  that  set  of  cerebral  symptoms  which 
follows  on  exhausting  disease,  especially  in  infants,  and  has  been 
described  under  the  name  of  "hydrocephaloid."  I  have  frequently 
seen  this  state  mistaken  for  primary  brain-disease.  The  child,  who  is 
most  often  the  subject  of  diarrhoea,  lies  in  an  apathetic  condition  with 
eyes  half  open,  is  with  difficulty  roused,  may  breathe  irregularly,  and 
often  sighs.  The  pupils  are  sluggish  and  often  unequal,  the  pulse 
frequent,  small,  and  sometimes  intermittent,  the  complexion  pale,  and 
the  skin  cool.  Probably  all  these  symptoms  may  be  explained  by 
imperfect  blood  supply  from  venous  stasis.  In  some  cases  there  is 
said  to  be  an  early  stage  of  restlessness  and  screaming,  with  great  sen- 
sitiveness to  light  and  noise,  frequent  pulse,  hot  skin  and  contracted 
pupils ;  but  such  a  stage  is  certainly  very  exceptional.  If  not  properly 
treated,  and  especially  if  actively  treated  by  "antiphlogistic"  measures, 
the  patient  is  in  imminent  danger  and  may  die  in  coma.  Alcoholic 
stimulation,  artificial  heat  and  good  nourishment  will  very  often  quickly 
relieve  or  cure.  In  these  cases  there  is  usually  no  fever,  except  some- 
times from  such  adventitious  causes  as  continuing  acute  diarrhoea  or 
a  concomitant  lung  affection ;  and  the  f  ontanelle  is  usually  much  sunken. 
With  due  care  and  inquiry  into  the  history  of  the  case  mistakes  in  diag- 
nosis should  scarcely  ever  occur.  The  ventricular  effusion  and  oedema 
of  the  pia  mater  which  are  found  in  some  of  these  cases  that  die  are 
due  to  venous  stasis  from  retarded  circulation  following  on  exhaustion. 
Sometimes  also  there  is  thrombosis  of  the  cerebral  sinuses. 

The  urine  should  be  examined  for  albumen  in  every  case  of  suspected 
meningitis  or  acute  brain  mischief,  for  many  cerebral  symptoms  are 
common  to  these  affections  and  to  acute  or  chronic  nephritis. 

Treatment. — A  careful  consideration  of  what  has  been  said  regarding 
the  diagnosis  and  course  of  meningitis  in  its  various  forms  will  make  it 
apparent  that  little  more  success  can  be  expected  than  is  actually  attained 
from  attempts  at  curative  treatment,  when  there  is  good  evidence  that  a 
discoverable  meningitis,  whether  tubercular  or  not,  has  been  established. 
Yet  we  can  rarely  or  never  know  for  certain,  from  symptoms,  when  the 
line  between  hypersemia  and  actual  exudation  has  been  crossed ;  and  we 
are  aware,  not  only  that  grave  cerebral  symptoms  in  connexion  with 
disturbed  blood  supply  very  frequently  pass  away,  but  also  that  actual 
meningitis  does  sometimes  spontaneously  recover. 

It  is  only  in  a  small  minority  of  cases  that,  either  in  hospital  or  private 
practice,  the  child  is  seen  in  the  earliest  stage  of  cerebral  disorder.  This 
is  the  time  when  good  may  possibly  be  done  by  purging  a  few  times  in 
cases  with  constipation,  by  the  abstraction  of  blood  by  means  of  leeches, 
and  by  the  administration  of  antimony,  opium  or  such  other  drugs  as 


ACUTE  DISEASES  OF  THE  BRAIN.  285 

may  l>c  believed  to  have  anti-inflammatory  action.  I  must,  however,  state 
that,  having  used  the  two  former  methods  very  often  and  the  latter  not 
seldom,  I  have  but  little  reason  to  place  faith  in  them ;  but  the  earlier  the 
case,  the  more  I  would  advise  this  procedure,  in  the  ascertained  absence 
of  the  "  hydrocephaloid "  condition  or  of  enteric  fever.  But  we  must 
remember  that  at  this  stage  enteric  fever  cannot  always  be  definitely 
diagnosed  or  excluded.  I  always  give  bromide  and  sometimes  iodide 
of  potassium  in  cases  which  come  under  notice  in  an  early  stage ;  the 
former  is  at  least  soothing  in  action,  and  the  latter,  besides  covering  cases 
of  possibly  syphilitic  origin,  is  believed  by  many  good  and  not  credulous 
authorities  to  be  of  use  in  meningitis  other  than  tubercular.  In  all  early 
cases  suspected  to  be  meningitis,  whether  tubercular  or  not,  the  hypo- 
phosphite  of  lime  or  soda  may  be  tried.  They  are  believed  by  some 
to  be  of  use,  and  are  certainly  harmless.  An  ice-bag  to  the  head  is 
occasionally  very  quieting  in  cases  with  much  headache,  but  its  appli- 
cation is  often  fruitless  owing  to  the  very  restlessness  it  is  intended  to 
relieve.  Mercury,  from  much  experience  of  it  in  past  years,  I  am  sure  is 
useless.  I  never  give  it  now,  believing  it  to  be  decidedly  objectionable 
in  cases  which  might  spontaneously  recover.  There  is  no  hindrance  to 
the  use  of  opium  or  chloral  in  certain  cases  marked  by  a  prolonged 
period  of  great  pain  and  restlessness ;  and  opium  may  be  given  in  early 
cases,  even  when  these  symptoms  are  not  marked. 

At  the  outset  the  ears  should  always  be  carefully  examined,  and  if, 
from  the  presence  or  a  previous  history  of  otitis  or  from  a  bulging  of  the 
tympanic  membrane,  there  be  a  suspicion  of  retained  pus,  free  evacuation 
should  be  secured  by  puncture,  and  the  meatus  stuffed  with  antiseptic 
wool. 

Every  suspected  case  must  be  kept  cool  and  quiet,  and  as  much  in  the 
dark  as  possible. 

In  advanced  stages,  or  when  increasing  drowsiness  or  any  paralysis  is 
observed,  the  best  that  we  can  do,  while  we  need  not  omit  the  iodide  or 
hypophosphite  which  may  have  been  given,  is  to  attend  to  the  patient's 
nourishment  with  the  faint  hope  of  the  remarkable  recovery  occasion- 
ally seen. 

Prophylaxis  can  only  apply  to  the  tubercular  form  of  meningitis,  which 
is  often  preceded  by  symptoms  due,  either  to  the  deposit  of  tubercle  in 
the  meninges  causing  hyperaemia  without  actual  exudation,  or  to  disease 
elsewhere.  In  suspected  or  actually  tubercular  cases,  therefore,  all 
sources  of  cerebral  excitement  should  be  carefully  guarded  against ;  and, 
when  possible,  children  of  markedly  tubercular  families  should  be 
similarly  protected.  We  may  be  well  advised  in  discouraging  much 
mental  labour  in  cases  of  delicate  children  with  close  phthisical  rela- 
tionships. 


2  86  DISORDERS  OF  THE  NERVOUS  SYSTEM. 


CHAPTER  IV. 

CHRONIC    DISEASES    OF    THE   BRAIN. 

The  brain  of  the  young  child  may  be  affected  by  many  of  the  patho- 
logical conditions  familiar  to  us  in  adults,  and  in  addition  by  extensive 
effusion  into  the  ventricles,  usually  described  as  chronic  hydrocephalus. 
After  dealing  with  the  last-named  affection  I  shall  give  a  short  account 
of  cerebral  haemorrhage,  embolism,  thrombosis,  tumours,  and  sclerosis,  as 
symptomatically  indicated  or  found  post-mortem  in  childhood. 

Chronic  Hydrocephalus. 

This  is  a  name  generally  given  to  a  well-known  class  of  cases  where 
there  is  increasing  enlargement  of  the  head,  in  connexion  with  an  effu- 
sion of  fluid  usually  ventricular,  but  sometimes  outside  the  pia  mater. 
Neither  on  unsuspected  ventricular  effusion  found  only  post-mortem  and 
occurring  in  tubercular  and  other  wasting  diseases,  nor  on  that  other 
important  form  without  much  or  any  head  enlargement,  which,  as  we 
have  seen,  [is  so  common  in  association  with  marked  meningitis,  is  it 
necessary  to  dwell  here.  I  would  nevertheless  emphasise  the  fact  that 
we  occasionally  meet  with  cases  in  young  children  of  intermittent 
pyrexia  with  much  irritability,  accompanied  by  paroxysms  of  more  or  less 
severe  pain  in  the  head  without  localised  paralysis  or  other  symptoms, 
where  practically  nothing  is  found  post-mortem  beyond  extensive  ven- 
tricular effusion.  Among  a  few  instances  of  this,  one  case,  which  I  saw 
in  the  practice  of  a  colleague  at  "Westminster  Hospital,  is  especially  pro- 
minent. The  child  was  two  years  old,  and  the  fontanelles  were  quite 
closed.  Symptoms,  as  above-mentioned,  endured  for  months;  a  high 
temperature,  sometimes  reaching  1040,  occurring  almost  daily.  There 
was  much  effusion  in  the  ventricles  but  no  post-mortem  sign  of  inflam- 
mation, with  the  exception  of  one  or  two  very  minute  spots  of  past 
meningitis. 

In  the  diagnosis  of  hydrocephalus  we  must  always  remember  the 
large  head  of  rickets,  where  the  fontanelles  are  alike  open  and  ossification 
is  retarded.  Observation  of  the  more  globular  shape  in  hydrocephalus, 
and  the  more  or  less  flattened  vertex  in  rickets,  will  prevent  confusion 
in  many  cases ;  but  it  must  be  remembered  that  a  considerable  propor- 
tion of  hydrocephalic  infants  are  also  rickety.  A  word  of  warning  is 
necessary  against  regarding  a  tense  or  pulsating  fontanelle  as  a  sign  of 


CHRONIC  DISEASES  OF  THE  BRAIN.  2S7 

hydrocephalus.  Such  a  phenomenon  may,  on  the  one  hand,  be  an 
accompaniment  of  acute  meningitis,  and,  on  the  other,  a  merely  tem- 
porary occurrence  in  the  course  of  various  febrile  conditions. 

The  skull-bones  in  hydrocephalus  are  nearly  always  very  thin,  although 
rarely  they  may  be  abnormally  thickened;  and  sometimes  there  is  an 
abundance  of  "ossa  triquetra,"  which  may  become  displaced  and  strikingly 
manifest  if  the  fluid  be  withdrawn  by  aspiration.  In  extreme  cases 
there  are  wide  intervals  between  the  bones,  and  sometimes  the  whole 
cranial  vault  is  made  up  of  mere  osseous  islets  in  the  surrounding 
membrane.  The  surface  veins  are  large,  and  the  hair  scanty.  The  eye- 
balls are  often  directed  more  or  less  downwards,  leaving  much  of  the 
whites  exposed ;  and  there  may  be  weakness  of  the  levatores  palpebrarum 
or  of  any  of  the  muscles  of  the  globes.  Frequently  there  is  optic  atrophy 
and  enlargement  of  the  fundal  veins,  and  the  eyesight  may  be  impaired 
in  any  degree.  Imperfect  vision  or  blindness  may,  however,  exist  with 
no  ophthalmoscopic  abnormality,  and  may  then  be  due  to  pressure  on  the 
cortical  centres.     The  sense  of  hearing  is  likewise  very  often  defective. 

Mental  impairment  of  any  grade  may  occur ;  although  in  some  cases, 
and  especially  in  those  where  the  affection  appears  to  have  set  in  late, 
but  little  or  no  deficiency  is  observed. 

In  many  instances  there  is  weakness  or  loss  of  motor  power  in  the 
legs,  and  sometimes  ataxia  of  the  upper  extremities.  Rigidity  of  limbs 
and  trunk,  and  tremors  on  movement  may  occur,  probably  connected 
with  pressure  on  the  cerebral  motor-tract ;  and  convulsions,  including 
glottic  spasm,  are  frequent.  Often  there  is  general  retardation  of  bodily 
development.  The  general  organic  health,  however,  may  remain  good 
for  long,  although  in  time  wasting  generally  sets  in.  In  marked  cases 
death  happens  mostly  early,  with  emaciation  and  often  with  convulsions ; 
but  sometimes  the  patients  last  for  several  years,  and  a  very  few  outlive 
childhood.  There  is  probably  a  considerably  greater  number  of  cases  of 
hydrocephalus  arrested  before  the  affection  has  become  extreme  than 
can  be  easily  demonstrated.  All  are  familiar  with  some  instances  of  this 
event,  where,  even  after  notable  enlargement  of  the  head  for  a  short 
time,  arrest  takes  place,  and  recovery  is  good  with  no  mental  or  physical 
impairment. 

The  origin  of  chronic  hydrocephalus  is,  as  a  rule,  obscure.  There 
is,  practically,  no  clinical  differentiation  possible  between  the  so-called 
"congenital"  and  "acquired,"  or  between  the  inflammatory  and  non- 
inflammatory cases.  Post-mortem  examination  often  shows  thickening 
and  roughness  of  the  lining  membrane  of  the  ventricles  and  the  choroid 
2?lexuses,  and  sometimes  lymph  is  found  obstructing  the  ventricular  com- 
munications. In  other  instances  absolutely  no  traces  of  inflammation  are 
seen.     In  the  congenital  cases  there  is  often  further  evidence  of  faulty 


288  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

development,  cerebral  or  otherwise.  Tumours  of  the  cerebellum  or  pons, 
though  often  occasioning  much  effusion  into  the  ventricles,  are  not 
frequent  causes  of  the  clinical  class  of  cases  under  notice,  comparatively 
seldom  giving  rise  to  very  notable  enlargement  of  the  head.  The  un- 
doubted inflammatory  origin  of  many  cases  is  only  sometimes  referable  to 
a  distinct  meningitis,  but  it  may  be  believed  that  such  an  affection  may 
have  existed  and  have  undergone  arrest.  Various  opinions  are  recorded 
as  to  the  connexion  between  hydrocephalus  and  syphilis.  In  my  experi- 
ence the  association  is  decidedly  frequent,  and  Fournier  and  others  have 
reported  instances  tending  to  support  the  view  that  this  association  is 
a  causal  one. 

In  a  large  majority  of  cases  the  enlargement  of  the  head  is  observed 
in  the  first  few  months ;  in  a  very  few,  examples  of  which  I  have  seen, 
the  pressure  of  the  effused  fluid  has  been  first  noticed  owing  to  the  re- 
opening of  already  closed  sutures.  In  a  case  of  a  child,  aged  five  years, 
where  the  sutures  re-opened,  there  was  found  a  slight  basic  meningitis 
which  had  closed  up  the  openings  of  the  fourth  ventricle. 

It  is  possible  that  non-inflammatory  ventricular  effusion  arising  in 
connexion  with  malnutrition,  and  an  imperfectly  developed  cranium 
leading  to  insufficient  antagonism  to  the  intra-vascular  pressure,  may  be 
much  encouraged  by  the  occurrence  of  additional  strain  on  the  cerebral 
vessels  from  such  a  cause  as  violent  coughing.  Hydrocephalus  certainly 
seems  sometimes  to  arise  clinically  out  of  lohooping-cough. 

Hydrocephalic  fluid  is  sometimes  clear  and  sometimes  turbid  with 
lymph  or  even  pus,  with  or  without  some  trace  of  blood.  In  the  clear 
fluid  of  apparently  non-inflammatory  cases  there  is  but  a  trace  of  albu- 
men, while  in  those  marked  by  signs  of  inflammation  albumen  may  be 
in  considerable  quantity. 

The  symptomatic  treatment  of  this  affection  is  very  unsatisfactory, 
nor  does  it  appear  to  me  that  there  have  been  any  direct  artificial  cures. 
We  know  that  some,  and  believe  that  many  cases  are  naturally  arrested 
with  improved  nutrition,  and  also  that  but  few  live  long,  however  treated, 
when  the  enlargement  of  the  head  has  been  great  and  rapid.  We  must 
before  all  things  attend  to  diet  and  hygiene,  giving  cod-liver  oil  and 
the  mineral  tonics,  and  appropriately  treat  any  concurrent  disease,  not 
forgetting  the  possibility  of  syphilis.  Following  such  methods  we  may 
sometimes  be  agreeably  surprised  at  the  result.  I  have  patiently  tried 
in  many  cases  the  effect  of  mercurials,  both  internally  and  externally,  of 
iodine  and  the  iodides,  and  of  other  medicines ;  I  have  bound  the  head 
with  elastic  and  other  bandages ;  and  on  three  occasions  I  have  aspirated 
the  fluid.  I  am  convinced  that  all  these  plans  are  useless,  and  that 
aspiration  is  more  likely  to  bring  discredit  on  the  physician  than  even 
temporary  relief  to  the  patient. 


CHRONIC  DISEASES  OF  THE  BRAIN.  289 


Cerebral  Haemorrhage,  Thrombosis  and  Embolism. 

Some  of  the  clinical  aspects  of  circulatory  obstruction  in  the  brain  are 
treated  of  under  the  heading  of  cerebral  paralysis.  From  a  practical 
point  of  view  there  is  but  little  to  add  concerning  the  above-named 
conditions,  which  have  much  that  is  common  in  their  symptomatology. 

Haemorrhage  into  the  meninges  is  frequently  met  with  in  the  new- 
born, and  is  mainly  due  to  injury  during  protracted  labour  or,  less 
often,  to  instrumental  delivery.  Sudden  increase  of  intra-cranial  pres- 
sure during  arrested  breathing,  and  notably  in  a  paroxysm  of  whooping- 
cough,  may  perhaps  determine  haemorrhage  even  with  healthy  vessels ; 
and  the  vascular  changes  which  may  take  place  in  the  course  of  such 
acute  infectious  diseases  as  scarlatina,  enteric  fever,  measles,  diphtheria, 
or  smallpox  are  doubtless  predisposing  causes  to  haemorrhage  variously 
excited.  Hereditary  syphilis,  too,  must  be  ranked  as  a  known  though 
infrequent  cause  of  vascular  disease.  Haemorrhage  into  the  substance 
of  the  brain  is  an  acknowledged  occurrence,  and  takes  place  most  often 
in  the  cortex. 

The  symptoms  of  meningeal  haemorrhage  in  the  new-born  are  convul- 
sions, coma  or  paralysis  observed  at  birth  or  soon  afterwards.  Mono- 
plegia, hemiplegia,  or  bilateral  paralysis  is  a  frequent  result  in  cases 
which  do  not  soon  die,  and  complete  recovery  probably  takes  place  in 
some  cases.  In  cerebral  haemorrhage  in  older  children  the  symptoms 
are  similar  to  those  in  adults,  depending  on  the  locality  of  the  lesion 
and  the  extent  of  the  haemorrhage.  With  slight  effusion  there  may  be 
rapid  recovery. 

Thrombosis  of  both  arteries  and  veins,  and  especially  of  the  sinuses,  is 
well-known  in  childhood  and  of  various  causation.  Syphilis  accounts  for 
some  cases,  and  instances  have  been  reported  in  the  course  of  diphtheria 
and  other  poison-diseases.  Sinus-thrombosis  occurs  in  exhausting  affec- 
tions, and  it  has  been  suggested  in  this  context  by  Dr.  Gowers  that 
thrombosis  of  the  superficial  cerebral  veins  may  explain  divers  cases  of 
hemiplegia  in  childhood.  A  common  cause  of  thrombosis  is  disease  in 
the  neighbourhood  of  the  sinus,  such  as  meningeal  inflammation,  tuber- 
cular or  other  wise,  injury  and  disease  of  the  skull-bones,  internal  ear 
mischief,  or  erysipelas  and  suppurative  processes  outside  the  skull.  The 
paralytic  symptoms  of  thrombosis  are  usually  gradual  in  onset,  preceded 
by  headache,  and  of  long  duration ;  varying,  of  course,  in  nature  and 
gravity  with  the  extent  and  locality  of  the  lesion. 

Embolism  may  occur,  in  children  as  in  adidts,  in  those  conditions 
which  involve  disease  of  the  heart-valves  or  favour  clotting  in  the  left 
side  of  the  heart,  especially  the  auricle.     Kheumatism  supplies  most  of 

T 


290  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

the  examples  of  this ;  scarlatina  and  other  infectious  diseases  a  few. 
In  young  children  the  subject  of  cerebral  embolism  is  not  extensive. 
The  symptoms  tend  to  be  sudden,  and  may  be  accompanied  with  con- 
vulsions, especially  when  the  vessels  of  the  cortex  are  implicated. 

Tumours  of  the  Brain. 

Tumours,  both  cerebral  and  cerebellar,  often  occur  in  childhood,  and 
are  not  very  rare  even  in  early  infancy.  Tubercular  tumours  are  by  far 
the  most  frequent,  and  form  a  very  large  proportion  of  all  cases  below 
the  age  of  seven,  becoming  gradually  rarer  in  later  years.  Next  in 
frequency  are  glioma  and  sarcoma,  or  a  mixed  form  of  these  growths. 
Others,  such  as  syphilitic  gumma,  myxoma  and  carcinoma,  are  but  very 
seldom  seen;  while  parasitic  cysts,  though  apparently  not  rare  in  Germany, 
are  scarcely  met  with  here. 

Tubercular  tumours  are  of  all  shapes  and  sizes,  varying  from  small 
aggregations  of  miliary  tubercles  to  large  caseous  masses ;  they  may  be 
single  or  multiple,  encapsulated  or  widely  diffused.  Although  occurring 
in  any  part,  the  most  favourite  seat,  especially  of  the  larger  ones,  is  in 
the  cerebellum  or  the  pons  and  its  neighbourhood.  They  very  often 
occupy  the  cortex,  and  frequently  originate  in  the  pia  mater.  Almost 
always  they  are  found  post-mortem  to  be  associated  with  tubercle  else- 
where ;  and  particularly  affect  scrofulous  or  tubercular  children  who 
have  often,  besides,  a  family  history  of  such  diseases.  The  symp- 
toms vary  much  according  to  the  size  and  position  of  the  tumours, 
which  may  be  of  very  different  duration.  In  some  the  symptoms 
may  endure,  with  remissions,  for  months  or  even  years ;  in  others, 
which  remain  latent,  the  first  symptoms  noticed  may  be  those  of  the 
meningitis  which  so  often  forms  the  fatal  chapter  in  their  clinical  history. 
Small  tubercular  tumours,  with  or  without  symptoms,  occasionally  become 
obsolete  through  cretification ;  and  large  caseous  ones  sometimes  form 
abscesses  which  may  be  the  foci  of  more  generalised  tuberculosis. 

Gliomata  may  occur  anywhere  in  the  substance  of  the  brain,  most  often, 
on  the  whole,  in  the  white  matter ;  they  do  not  involve  the  pia  mater. 
The  pons  is  a  very  favourite  seat.  They  may  be  hardish,  or  very  soft ; 
fairly  well-defined,  or  with  no  limitation  from  the  surrounding  brain 
substance ;  and  often  attain  a  great  size.  Their  growth  is  sometimes 
very  slow.  In  one  case,  aged  thirteen,  where  definite  symptoms  of 
brain-disease  had  lasted  off  and  on  for  nearly  six  years,  I  found  the 
whole  of  one  temporo-sphenoidal  lobe  involved  in  a  glioma,  the  rest  of 
the  body  being  quite  healthy.  The  harder  and  more  definite  tumours 
may  soften  and  break  down,  and  there  is  in  all  a  liability  to  internal 
or  circumferential  haemorrhage  owing  to  their  vascularity. 


CHRONIC  DISEASES  OF  THE  BRAIN.  2QI 

Sarcomata  may  bo  found  in  any  part  of  the  cerebrum  or  cerebellum, 
or  may  start  in  the  membranes  or  from  the  bones.  They  arc  usually 
round-  or  spindle-celled,  for  the  most  part  grow  very  rapidly,  and  are 
seldom  multiple.  They  are  mainly  seen  in  early  childhood,  and  are 
unassociated  with  similar  disease  elsewhere.  They  have  undoubtedly 
a  close  clinical  and  anatomical  relationship  with  gliomata. 

Concerning  the  general  aetiology  of  brain  tumours  I  can  but  endorse 
from  my  own  experience  the  usual  confession  of  ignorance  and  the 
perhaps  equally  usual  belief  that  in  many  cases,  difficult  as  proof  may 
be,  severe  blows  and  falls  on  the  head  are  the  real  starting-point. 
It  is  at  least,  I  think,  very  probable  that  such  accidents  may  occasion 
the  growth  of  tumours  of  all  the  kinds  above  mentioned,  though  of 
course  in  many  instances  tubercular  tumours,  especially  when  small 
and  multiple,  must  be  regarded  as  merely  expressions  of  a  general 
tuberculosis. 

The  symptoms  indicating  tumour  within*  the  cranium  are  usually 
described  in  two  classes,  general  and  local ;  the  first,  such  as  headache, 
vomiting,  optic  neuritis,  and,  we  may  add,  bilateral  convulsions  with 
affection  of  consciousness,  being  as  a  rule  common,  some  or  all  of  them, 
to  all  brain  tumours  in  infancy  of  whatever  position ;  the  second,  such 
as  unilateral  or  local  spasms  and  paralyses,  in-coordination  and  disturb- 
ance of  equilibrium,  and  affections  of  sensibility,  speech,  swallowing 
or  respiration,  being  referable  to  the  position  of  the  lesion  in  the 
brain,  of  whatever  kind  it  may  be,  and  often  more  or  less  exactly 
indicating  that  position.  From  a  practical  point  of  view,  however,  and 
especially  in  relation  to  these  affections  in  childhood,  such  a  division 
seems  to  be  of  little  worth.  Localising  symptoms  are  often  absent 
altogether  when  the  tumour  occupies  certain  parts  of  the  brain,  a  fact 
which,  especially  in  infants  and  young  children  who  cannot  express 
themselves,  may  render  the  diagnosis  obscure  for  long;  and  the  con- 
vulsions so  very  frequently  associated  with  brain  lesions  in  infancy, 
being  often  general,  are  devoid  of  localising  value,  and  indistinguishable 
from  those  which  are  independent  of  coarse  disease  and  classed  as 
idiopathic  convulsions  or  epilepsy.  I  shall  indeed  pass  over  with  but 
short  notice  the  matter  of  localising  symptoms  in  cases  of  brain  tumours, 
as  neither  special  to  our  subject  nor  sufficiently  illustrated  in  my  own 
experience  by  post-mortem  examinations  in  children.  Several  of  my 
best  cases  were  taken  out  of  hospital  before  death,  and  in  several  others 
the  necropsy  was  forbidden. 

An  early  and  enduring  symptom  of  tumour  in  the  brain  is  headache, 
which  is  often  severe  and  may  be  either  constant  or  recurrent.  In  cases 
of  growing  tumour  there  is  probably  always  some  headache  with  frequent 
exacerbations.     The  seat  of  pain  is  but  rarely  an  indication  of  the  seat 


292  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

of  the  disease  as  proved  post-mortem ;  but  my  experience  is  certainly  in 
accord  with  that  of  many  observers  who  note  frequent  concomitance  of 
constant  occipital  pain  with  tumours  of  the  cerebellum  or  bulb.  I  have, 
however,  seen  several  cases  where  all  other  symptoms  of  tumour  were 
well-marked,  both  in  infants  and  children  who  could  speak ;  and  some 
where  a  cerebellar  tumour  was  found  post-mortem,  in  which  there  was 
for  long  but  little  evidence  of  headache,  and  the  patients,  with  intervals 
of  slight  paroxysmal  pain,  were  quite  cheerful. 

Convulsions  of  general  distribution,  with  impairment  or  loss  of  con- 
sciousness, are  very  frequent,  and  are  recorded  in  many  histories  as  the 
first  noticed  phenomena.  In  several  cases,  where  the  symptoms  were 
those  of  cerebellar  or  of  pontine  growth,  general  and  repeated  convulsions, 
slight  or  severe,  occurred  very  early.  It  is  only  when  a  convulsion,  limited 
to  one  side  or  to  one  muscular  group,  is  recurrent,  and  especially  when 
it  is  not  accompanied  by  marked  evidence  of  defect  of  consciousness,  that 
it  becomes  a  valuable  evidence  of  a  lesion  in  or  close  to  the  motor  cortex 
of  the  opposite  side  of  the  brain. 

Vomiting  at  intervals,  often  unexcited  by  any  discoverable  cause,  occurs 
in  most  cases,  wherever  the  tumour  may  be  :  and  in  connexion  with  con- 
stant headache  is  a  very  serious  warning.  Optic  neuritis,  which  in  some 
degree  is  present  in  a  very  large  majority  of  cases,  is  of  value  as  a  sign 
which  may  help  us  at  once  to  distinguish  some  severe  cases  of  frequently 
recurrent  migraine  from  cerebral  tumour.  It  may  exist  for  long  without 
producing  any  complaint  of  visual  trouble,  is  usually  double,  and,  though 
it  accompanies  tumours  of  any  kind  or  seat,  is  especially  frequent  with 
those  of  the  cerebellum  and  the  base  of  the  brain  and  then  often  causes 
early  blindness.  Optic  neuritis  is  however  by  itself,  as  is  well  known, 
no  absolute  proof  of  brain-disease,  even  when  other  symptoms  seem  to 
indicate  such  mischief.  Messrs.  Ashby  and  Wright  record  a  case  of 
otitis  without  cerebral  disease  in  which  optic  neuritis  was  observed. 
Vertigo  is  a  feeling  complained  of  in  most  cases  from  time  to  time, 
although  it  is  most  constant  in  the  case  of  cerebellar  tumours  where 
there  is  also  evidently  faulty  equilibrium.  Nystagmus  is  frequently 
observed,  especially  with  tumours  in  the  cerebellum  or  pons.  Droivsiness, 
irritability,  and  all  kinds  of  mental  changes,  from  apathy  to  delirium  and 
acute  maniacal  excitement,  may  frequently  be  noted,  very  few  cases  being 
unmarked  by  any  kind  of  psychical  disturbance.  When  the  pain  is 
great  and  continuous  there  may  be  persistent  insomnia.  Most  growing 
tumours  are  accompanied  by  toasting,  which  is  especially  marked  in 
long-standing  cerebellar  cases.  Instances  are  common  where  children 
continue  steadily  wasting  for  weeks  or  months  after  vomiting  may  have 
ceased  and  pain  is  no  longer  evident,  dying  at  last  from  gradual  failure 
of  the  nervous  centres  and  sometimes  with  convulsions.     In  one  chronic 


CHRONIC  DISEASES  OF  THE  BRAIN.  293 

case  with  the  symptoms  of  brain  tumour,  but  not  examined  post-mortem, 
there  was  a  sudden  arrest  of  breathing  and  discoverable  heart-action,  the 
pulse,  however,  returning  with  artificial  respiration  performed  at  intervals, 
and  remaining  palpable  for  more  than  an  hour  after  all  signs  of  respira- 
tion had  ceased.  In  cases  of  tumour  at  the  base,  especially  of  the  cere- 
bellum and  pons,  pressure  on  the  veins  very  frequently  causes  effusion 
into  the  lateral  ventricles,  and  various  degrees  of  hydrocephalus  may  be 
found.  At  the  same  time  great  enlargement  of  the  head,  even  in  infants, 
is  not  so  frequent  as  we  might  be  led  to  expect.  Death  in  cerebral 
tumours  may  take  place  from  pressure  on  the  vital  parts  in  the  medulla, 
is  often  coincident  with  convulsions,  and  very  frequently  the  result  of  a 
meningitis  set  up  by  the  growth. 

The  presence  of  several  or  all  of  the  above-mentioned  symptoms  is  a 
strong  indication  of  brain  tumour ;  and  if,  in  addition,  there  are  definite 
local  spasms  or  paralyses  or  other  signs  of  limited  lesion,  such  as  altered 
gait,  impairment  of  speech,  breathing,  swallowing  or  the  like,  the  diag- 
nosis is  tolerably  certain.  In  the  absence,  moreover,  or  indistinct  presence 
of  many  of  the  so-called  general  symptoms,  these  local  manifestations  are 
of  the  greatest  importance. 

Passing  by  the  whole  subject  of  the  differential  diagnosis  of  the 
various  sites  of  tumours  of  the  cerebrum  proper,  which  is  a  matter  of 
the  knowledge  of  cerebral  topography,  I  shall  but  shortly  deal  with 
those  of  the  cerebellum,  which  are  by  far  more  frequent  in  childhood 
than  in  later  life ;  touching  also,  incidentally,  on  the  almost  equally 
frequent  tumours  of  the  pons. 

The  chief  characteristic  of  cerebellar  as  distinguished  from  other 
tumours  is  disturbance  of  equilibrium,  especially  shown  by  a  more  or 
less  general  ataxia  when  the  body  is  unsupported,  without  any  true 
paralyses.  Thus  the  body  swings  in  standing  and  walking,  and  also, 
though  in  early  cases  to  a  less  extent,  in  sitting.  Some  uncertainty 
is  also,  I  think,  observable  sometimes  in  the  large  movements  of  the 
arms,  and  there  is  often  difficulty  in  holding  them  erect ;  while  the  child 
can  use  its  hands  well  when  the  body  is  at  rest  with  the  arms  supported. 
Thus  it  may  be  in  defect  of  equilibrium,  not  only  of  the  body  generally 
but  also  of  the  limbs  in  certain  positions,  that  the  so-called  cerebellar 
ataxia  is  evidenced. 

But  apart  from  the  great  fact  of  defective  equilibration,  seen  in  both 
station  and  locomotion,  which  is  undoubtedly  a  sign  of  failure  of  cere- 
bellar action  and  is  connected  with  disease  of  the  middle  lobe  of  that 
organ,  symptoms  of  cerebellar  disease  may  be  inextricably  confused  by 
those  of  the  involvement  of  other  parts,  and  especially  of  the  pons 
and  medulla  which  are  so  often  comcidentally  affected  both  directly 
and  indirectly. 


294  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

The  motor  tract  in  these  bodies  is  exceedingly  often  pressed  upon  by 
tumours  of  the  cerebellum,  while,  on  the  other  hand,  the  cerebellum  or 
its  peduncles  may  be  interfered  with  by  tumours  growing  from  the  pons 
or  its  neighbourhood;  and  the  rigidity  and  tremors  which  are  so  fre- 
quently seen  in  these  cases,  as  also  the  exaggerated  knee-jerks,  are  in  all 
probability  the  result  of  disturbance  in  this  tract.  It  is  said  by  many 
that  the  knee-jerks  are  either  exaggerated  or  at  least  not  abolished  in 
disease  of  the  cerebellum  itself.  I  have,  however,  observed  that  not  only 
spasms  and  rigidity,  as  Sharkey  has,  I  think,  satisfactorily  demonstrated, 
but  also  exaggerated  knee-jerks  are  apparently  confined  to  cases  where  the 
cerebral  motor  tract  is  affected,  either  by  the  growth  or  by  indirect  pres- 
sure. On  the  other  hand,  in  two  cases  regarded  during  life  as  cerebellar 
tumour,  where  the  middle  lobe  of  the  cerebellum  was  found  post-mortem 
to  be  largely  occupied  by  a  tubercular  and  a  sarcomatous  tumour  respec- 
tively, with  no  apparent  pressure  on  the  cerebral  motor- tract,  there  was 
no  rigidity  or  fine  tremor  on  movement,  and  the  knee-jerks  were  entirely 
absent  throughout.  I  mention  this  only  as  an  indication,  wanting,  of 
course,  much  more  observation  for  its  establishment,  that  the  presence 
of  knee-jerks  may  probably  imply  some  degree  of  cerebellar  activity ; 
that  destructive  cerebellar  disease  probably  causes  diminution  or  loss  of 
the  knee-jerks ;  and,  therefore,  that  this  phenomenon  cannot  be  regarded 
as  a  diagnostic  point  between  the  so-called  cerebellar  and  spinal  or 
peripheral  ataxia.1  The  diagnosis  of  the  locality  of  brain  tumours  is 
very  often  obscured  by  multiplicity  and  indefiniteness  of  lesion ;  and  we 
but  very  seldom  meet  clinically  with  the  pure  symptoms  of  cerebellar 
disease  alone. 

General  convulsions  occur  in  the  history  of  cases  of  cerebellar  tumour 
quite  as  often  as  in  that  of  others,  being  frequently  among  the  first 
symptoms  noticed.  In  my  experience  the  opisthotonic  seizures,  described 
as  peculiarly  cerebellar  in  origin,  are  very  rare.  Among  many  cases  of 
cerebellar  and  pontine  tumours,  either  demonstrated  or  suspected,  I  have 
but  rarely  seen  any  fits  during  their  long  residence  in  hospital  until 
meningitic  symptoms  set  in  and  death  was  imminent. 

Tumours  of  the  pons  may  be  suspected  or  diagnosed  from  motor 
paralysis,  especially  when  it  is  bilateral  or  crossed,  the  cranial  nerves 
being  affected  on  one  side,  the  limbs  on  the  other;  and  involvement 
of  the  medulla  is  often  indicated  by  altered  breathing  or  heart-rhythm, 
or  by  impaired  deglutition.     I  have,  however,  occasionally  been  surprised 

1  Since  writing  the  above,  I  have  read  the  report  of  a  case  by  Dr.  Handford  in 
Brain  (Part  LIX.  and  L.X.,  1892,  p.  458),  of  "cerebellar  tumour  with  loss  of  the 
knee-jerks,"  which,  with  Dr.  Handford's  comment,  corroborates  this  view.  In  this 
instance  the  whole  of  the  middle  lobe  of  the  cerebellum  was  destroyed  by  a  sarco- 
matous growth,  and  the  medulla  was  somewhat  flattened  thereby ;  but  the  knee-jerks 
were  throughout  entirely  absent. 


CHRONIC  DISEASES  OF  THE  BRAIN.  295 

at  finding  tumours  of  considerable  size  occupying,  and  apparently  grow- 
ing from,  the  floor  of  the  fourth  ventricle,  where  there  were  no  bulbar 
symptoms  until  quite  the  end  of  the  case. 

In  making  the  general  diagnosis  of  brain  tumours  we  should  remember 
that  the  symptoms  may  be  more  or  less  latent,  and  may  sometimes  very 
closely  simulate  those  of  chronic  meningitis,  of  cerebral  abscess,  or,  when 
the  effusion  and  head-enlargement  secondary  to  pressure  by  the  tumour  are 
exceptionally  great,  of  chronic  hydrocephalus ;  and  that  in  some  patients 
approaching  the  period  of  puberty  hysterical  symptoms  are  sometimes 
easily  mistaken  for  those  of  tumour,  or  the  two  affections  may  co-exist, 
the  hysterical  phenomena  being,  as  it  were,  grafted  on  the  more  serious 
nervous  disorder  and  greatly  obscuring  it. 

Although  some  cerebral  tumours  may  be  latent  for  long  and,  even 
when  symptomatically  evidenced,  may  still  run  a  protracted  course,  the 
prognosis  must  almost  always  be  that  of  a  fatal  result.  In  children 
there  is  scarcely  ever  the  possible  chance,  present  in  some  adult  cases  of 
syphilitic  tumour,  of  arrest  by  specific  remedies.  Such  medication,  how- 
ever, is  often  tried  as  a  forlorn  hope.  "When  therefore  the  locality  of  the 
tumour  has  been  diagnosed  with  the  best  approach  to  accuracy,  according 
to  modern  knowledge  of  cerebral  topography,  it  is  clearly  justifiable  to 
advise  recourse  to  trephining  and  possible  extirpation,  however  little 
ultimate  success  may  have  as  yet  been  attained  by  these  methods. 

Sclerosis  of  Nervous  Centres. 

With  regard  to  this  condition,  whether  diffused  or  disseminated  or 
limited  to  a  few  small  patches,  I  can  but  say,  with  Dr.  Goodhart  and 
others,  that,  although  occasional  examples  of  it  in  the  brain  are  un- 
doubtedly found  post-mortem,  our  clinical  knowledge  of  any  symptoms 
connected  therewith  is  very  scanty.  I  have  seen  cases,  where  small 
patches  of  sclerosis  have  been  unexpectedly  found  in  the  brain,  which 
were  marked  during  life  by  no  salient  nervous  symptoms ;  and,  on  the 
other  hand,  I  have  sometimes  met  with  groups  of  symptoms,  more  or 
less  similar  to  those  referred  to  disseminated  sclerosis  as  best  known 
in  adults,  which  either  diminished,  or  disappeared,  or  remained  without 
further  development.  I  have  never  had  an  opportunity  of  seeing  the 
brain  in  any  such  case.  With  extensive  sclerosis  as  the  occasional  result 
of  a  chronic  meningo-cerebritis  there  is  marked  mental  failure  or  idiocy ; 
with  small  and  localised  patches  due  to  some  inflammation  or  softening 
there  may  be,  as  has  been  said,  no  symptoms  at  all. 

Cases  have  been  described  by  several  observers  as  "multiple  "  or  "dis- 
seminated "  or  "  cerebro-spinal "  sclerosis  occurring  in  children,  the  symp- 
toms being  more  or  less  the  same  as  in  the  adult  disease,  but  more  often 


296  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

beginning  suddenly  with  tremors  after  a  convulsion.  For  a  comprehensive 
resume"  and  comment  on  the  literature  of  this  subject  I  would  refer  to 
Dr.  Pritchard's  article  in  Keating's  Cyclopaedia  of  the  Diseases  of  Children, 
where,  however,  the  symptomatic  and  anatomical  disquisition  is  chiefly 
based  on  the  recognised  disease  as  known  in  adults.  A  few  of  the  cases 
quoted  seem,  from  the  clinical  point  of  view,  to  have  full  claim  to  be 
classed  in  this  category ;  but  the  author  states  that  in  a  much  larger 
number  the  diagnostic  data  are  far  less  decisive.  Of  the  latter  variety 
I  think  I  have  seen  several  examples.  They  were,  however,  cases  which 
I  am  as  yet  unable  to  classify.  The  chief  symptoms  were  tremor,  in- 
creased or  occurring  only  on  movement,  varying  degrees  of  ataxia,  and 
sometimes  nystagmus.  I  have  elsewhere  referred  to  this  when  speaking 
of  paralysis  after  acute  disease,  some  examples  having  occurred  in  such 
a  connexion.  Without  more  post  mortem  observation,  it  is,  I  think, 
impossible  to  dogmatize  about  this  affection  in  childhood ;  the  symptoms 
of  the  recognised  type  in  adults  are  confessedly  variable,  from  the  very 
nature  of  the  disease  ;  and  it  seems  unadvisable  to  attempt  a  systematic 
account  of  "  disseminated  sclerosis  "  in  childhood  which  must  be  based 
almost  entirely  on  clinical  conjecture.  All  that  may  be  said,  considering 
the  extremely  scanty  anatomical  knowledge  concerning  this  disease  in 
children,  is  that  its  occurrence  in  some  of  the  cases  referred  to  is  at  least 
highly  probable.  Closely  allied,  symptomatically,  to  many  of  the  instances 
described  as  multiple  sclerosis  are  the  rare  disease  known  as  Friedreich's 
ataxia  or  hereditary  tabes  (for  a  description  of  which  I  refer  to  the  text- 
books), some  cases  of  brain  tumour,  and  some  of  chronic  meningitis. 
In  cases  of  this  ill-defined  class  we  may  practically  regard  the  presence  of 
nystagmus,  optic  atrophy,  definite  local  paralyses  either  sensory  or  motor, 
rigidity,  recurrent  convulsions,  and  marked  headache  as,  each  and  all,  more 
or  less  strongly  indicative  of  organic  disease,  and  consequently  as  of 
bad  prognosis ;  while  we  should  hesitate  long  before  condemning  those 
cases  which  are  marked  mainly  by  ataxia  and  tremors,  whatever  be  the 
condition  of  the  knee-jerks.  When,  however,  marked  knee-jerks  with 
ankle-clonus  are  demonstrable  in  childhood  and  continue  indefinitely,  the 
symptoms  are  of  grave  prognostic  import  as  to  ultimate  recovery. 


CHOREA.  297 


CHAPTER  V. 

CHOREA. 

In  treating  of  this  well-known  but  much  discussed  disorder  I  shall  but 
scantily  describe  it  and  make  no  attempt  at  reviewing  the  numerous 
and  conflicting  theories  of  its  aetiology.  I  have  chosen  rather  to  give,  as 
briefly  as  practicable,  the  results  of  my  own  observations,  based  on  a  study 
of  much  larger  numbers  of  out-  and  in-patients  than  are  included  in  the 
series  to  be  referred  to  in  some  detail,  and  on  the  consideration  of  much 
that  has  been  weightily  and  diversely  written  on  the  subject.  In  illus- 
tration of  various  points  I  have  analysed  162  cases  under  fourteen  years 
old  observed  in  my  wards  at  Shadwell  Hospital,  a  series  which  has  many 
advantages  over  those  which  include  out-patients  only ;  and  have  also 
made  use,  in  some  respects,  of  the  registrars'  abstracts  of  178  cases  under 
the  care  of  my  colleagues  and  myself  at  Westminster  Hospital.  The 
histories  of  these  were  taken  by  many  different  hospital  residents  from 
numerous  medical  schools  in  London  or  elsewhere,  and  the  records  as  a 
whole  are  probably  freer  than  some  from  the  drawbacks  of  bias  so  difficult 
to  eliminate  from  the  notes  of  a  single  observer. 

Chorea  is  described  by  Sturges1  as  an  "exaggerated  fidgetiness,  an 
extravagant  exaltation  of  that  continual  unrest  which  is  the  natural 
characteristic  of  childhood."  These  words  give  both  the  true  pattern  of 
the  disease  and  the  best  key  to  its  explanation.  The  typical  picture  of 
chorea,  as  well  as  its  varying  grades  of  severity,  I  assume  to  be  familiar 
to  all  of  any  practical  experience.  It  is  essentially  a  disorder  of  child- 
hood, affecting  the  female  sex  nearly  three  times  as  often  as  the  male, 
and  tending  almost  always  to  recovery ;  and,  though  it  may  recur  many 
times  or  even  persist  indefinitely,  its  onset  in  later  years  is  rare  and 
almost  always  associated  with  some  kind  of  psychical  disorder.  In  its 
ordinary  form  its  age  limit  is  mostly  from  six  to  fifteen.  The  youngest 
patients  observed  by  myself  were  two  girls  of  three.  Out  of  310  cases 
under  fifteen  years  there  were  two  boys  and  two  girls  under  five,  150 
between  five  and  ten,  of  whom  65  per  cent,  were  girls,  and  156  between 
ten  and  fifteen,  of  whom  78  per  cent,  were  girls.  After  puberty  the 
proportion  of  females  affected  is  overwhelming. 

The  characteristic  movements  begin  either  gradually,  as  an  almost 
imperceptible  increase  of  fidgetiness  ;  or  suddenly,  with  or  without  ascer- 
tained exciting  causes.  They  usually  affect  the  hands  first,  and  tend 
1  See  "  Chorea,"  Smith  &  Elder,  18S1. 


298  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

to  become  more  or  less  general  in  a  large  majority  of  cases,  the  upper 
part  of  the  body  almost  always  suffering  most.  In  the  older  children 
facial  grimace  is  sometimes  the  first  observed  symptom.  For  a  full 
consideration  of  the  place  of  origin  and  of  the  distribution  of  choreic 
movements  I  would  refer  to  the  work  of  Sturges,  who  shows  that  the 
more  specialised  muscles,  or  those  most  in  want  of  control,  are  usually  the 
first  to  suffer  and  are  always  most  affected  throughout  the  disorder.  In 
61  of  my  own  cases,  where  special  inquiry  was  made  on  this  point,  the 
movements  were  first  noticed  in  both  hands  in  6,  the  right  hand  in  6, 
the  right  hand,  arm  and  leg  in  6  (several  of  all  these  having  the  face 
affected  as  well,  either  at  once,  or  very  soon),  the  right  arm  and  leg  in  1 , 
the  right  arm  and  face  in  3,  the  face  in  3,  both  arms  in  2,  both  legs  in 
2,  one  leg  in  1,  the  left  arm  and  leg  in  10,  the  left  arm  in  4,  the  left 
hand  in  1  ;  in  the  rest  the  movements  were  said  to  be  general  from  the 
first,  with  an  almost  universal  preponderance  in  the  hands  and  arms.  In 
all  my  cases  I  find  only  three  possible  instances  of  movements  confined 
to  one  side  throughout ;  but  the  notes  of  these  are  but  scanty,  and  I  am 
well  convinced,  from  observation  of  numerous  alleged  cases  of  "hemi- 
chorea,"  that  strictly  unilateral  choreic  movements  of  prolonged  duration 
are  of  remarkable  rarity  in  childhood,  if  indeed  they  ever  occur. 

The  face,  especially  in  the  older  children,  rarely  escapes  altogether ; 
the  eye-movements  are  frequently  affected;  and  the  muscles  of  respiration, 
of  speech,  and  pre-eminently  the  tongue,  mostly  suffer  in  some  degree. 
In  some  severe  cases  chewing  and  swallowing  may  be  difficult  or  im- 
possible, and  the  patients  may  need  to  be  fed  by  the  nasal  tube.  Some- 
times the  movements  are  exceedingly  violent,  the  patients  injuring 
themselves  against  the  bedstead  and  even  jerking  themselves  out  of  it 
if  not  properly  protected  and  watched. 

Some  amount  of  weakness  (or  "  paresis  ")  of  the  affected  limbs  always 
obtains,  and  marked  paralysis  after  the  movements  have  subsided  is  not 
nearly  so  uncommon  as  is  often  taught.  I  have  seen  numerous  instances 
of  this,  including  four  of  complete  paralysis  of  all  the  voluntary  muscles, 
with  faltering  heart,  irregular  breathing  and  great  difficulty  of  swallow- 
ing, lasting  from  one  to  three  weeks.  Such  patients  are  apt  to  become 
fatuous,  to  waste  excessively  and  to  suffer  from  bed-sores.  Three  of  the 
four  mentioned  made  complete  recovery  and  one  died. 

The  movements  almost  always  cease  during  sleep  and,  in  most  cases, 
are  increased  by  attention  called  to  them  or  by  attempts  at  coercion ; 
but  in  a  considerable  minority,  especially  in  older  children,  they  can  be 
greatly  controlled  by  voluntary  effort.  I  have  notes  of  many  patients 
who  were  always  quieter  when  being  talked  with  or  when  endeavouring 
to  exert  control.  In  properly  chosen  cases  this  fact,  often  contradicted 
or  overlooked,  gives  useful  indications  for  treatment. 


CHOREA.  299 

Emotional  disturbance  is  marked  in  very  many  cases  even  in  little 
children,  but  especially  in  those  over  ten  years ;  and  may  precede  the 
motor  symptoms  for  some  time.  Analgesia  of  varying  extent,  especially 
in  the  parts  most  affected  by  movements,  is  not  seldom  met  with,  but 
is  rare  in  early  childhood.  I  have,  however,  seen  one  well-marked 
instance  in  a  child  of  three.  Very  various  hysterical  phenomena  often, 
and  definite  mental  disturbance  sometimes,  occur  in  the  older  cases ; 
but  I  am  of  opinion  that  the  intellectual  powers  of  most  choreic  children 
are  not  below  the  average,  and  that  psychical  disorder  is  mostly  shown 
in  the  sphere  of  feeling. 

Dilatation  with  or  without  sluggishness  of  the  pupils  is  a  very  fre- 
quent phenomenon,  most  often  disappearing  on  recovery ;  and  inconti- 
nence of  urine,  apart  from  definite  cases  of  choreal  paralysis  where  it 
is  the  rule,  is  not  so  rare  as  I  once  thought. 

The  heart's  action  is  almost  always  accelerated,  often  irregular  in 
force  and  rhythm— a  fact  surprisingly  often  denied — and  in  a  large 
number  of  cases,  besides  those  with  the  rheumatic  endocarditis  pre- 
sently to  be  noticed,  there  are  either  distinct  murmurs,  or  reduplication  or 
alteration  of  the  sounds.  With  respect  to  the  cardiac  irregularity  which 
seems,  as  Sturges  teaches,  to  be  more  marked  in  younger  subjects,  we 
must  remember  that  in  a  slight  degree  it  is  physiological  in  early  child- 
hood. The  special  cardiac  signs  of  chorea  I  shall  discuss  separately, 
but  it  may  be  said  here  that  "  haemic  "  murmurs,  either  confined  to  the 
base  or  ventricular  as  well,  with  loud  humming  sounds  in  the  cervical 
vessels,  are  very  frequent,  and  sometimes  occasion  difficulty  in  the 
observation  or  discussion  of  heart-affection  in  chorea. 

The  temperature  of  the  body  is  notably  subnormal  throughout  in  a 
large  number  of  cases,  being  often  as  low  as  97°  or  960,  as  is  abundantly 
shown  by  routine  observation  during  many  years  at  Shadwell  Hospital. 
I  have  but  rarely  noticed  a  rise  of  temperature  at  the  height  of  severe 
attacks,  and  believe  from  the  cases  I  have  seen  (a  few  of  them  being 
strongly  marked  in  older  children  and  adults,  and  attended  by  mental 
disturbance  or  even  mania)  that  it  is  probably  due  to  causes  not  proper 
to  chorea. 

Chorea  has  a  great  tendency  to  recur  at  varying  intervals,  about  one- 
third  of  my  cases  being  admitted  in  at  least  their  second  attack  and 
several  in  their  fourth  or  fifth.  Further  salient  points  in  the  clinical 
history  of  chorea,  and  bearing  importantly  on  its  aetiology,  are  its 
close  association  with  other  nervous  phenomena  and  definite  hereditary 
neuroses ;  its  very  frequent  excitation  by  special  nerve-disturbances 
which  are  evidenced  by  various  emotions,  especially  fright,  immediately 
preceding  the  attacks ;  and  the  notable  proportion  of  cases  which  are  the 
subjects  of  rheumatism  or  have  a  distinctly  rheumatic  family  history. 


300  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

I  shall  now  notice  briefly  the  relationships  of  chorea  to  rheumatism 
and  to  heart-affections  respectively,  postponing  the  matter  of  the  nervous 
excitants  and  associations  of  the  disorder  until  I  remark  on  its  aetiology. ' 

The  relationship  between  Rheumatism  and  Chorea  is  sufficiently  fre- 
quent to  necessitate  its  consideration  with  regard  to  aetiology.  In  a  small 
number  of  cases  chorea  occurs  in  the  course,  or  as  the  immediate  sequel, 
of  an  attack  of  acute  rheumatism  ;  and  a  considerably  larger  number 
of  choreic  patients  suffer  from  rheumatism  at  some  time  or  other  before 
or  after  the  chorea.  It  is  also  stated  by  many  that  there  is  an  unduly 
great  proportion  of  rheumatism  in  the  families  of  choreics  ;  and,  further, 
there  are  those  who  so  exalt  and  magnify  the  part  played  by  rheumatism 
in  the  production  or  encouragement  of  chorea  as  almost  to  incur  the 
logical  necessity  of  admitting  no  other  mode  of  causation.  It  is  clear 
that  to  be  accurate  in  this  matter  we  must  be  definite  in  our  use  of  the 
term  "  rheumatism  "  and  have  an  approximate  notion  of  its  usual  inci- 
dence on  the  population.  It  must  be  borne  in  mind,  however,  that  acute 
rheumatism  occurs  often  in  childhood  with  but  little  or  even  no  demon- 
strable arthritis,  and  I  have  consequently  been  careful  to  include  in 
the  "rheumatic"  class  of  cases  of  chorea  all  those  with  pericarditis,  or 
with  endocarditis  marked  by  symptoms  or  signs  other  than  a  mere  apex 
murmur,  as  well  as  many  others  which  might  be  very  doubtfully 
called  rheumatic,  and  some  with  limb-pains  and  especially  wrist-pains 
which  were  probably  not  rheumatic  at  all.  Even  with  this  very  liberal 
construction  of  rheumatism  I  cannot  class  more  than  35  per  cent,  of 
my  chorea  cases  as  in  any  sense  rheumatic.  Inquiry  as  to  family 
rheumatism  is  difficult  and  often  unsatisfactory,  especially  among  the 
working-classes  on  whom  chorea  is  chiefly  incident ;  but,  after  many 
investigations  on  this  point,  including  over  90  cases  of  chorea  where 
the  histories  were  fairly  ascertainable,  I  find  that  rheumatism  occurred 
in  about  30  per  cent,  of  the  immediate  families  of  choreics,  and  that 
rather  more  than  half  of  these  rheumatic  families  belonged  to  children 
who  had  themselves  suffered  from  rheumatism.  The  ordinary  incidence 
of  rheumatism  on  those  who  frequent  London  hospitals  from  all  causes 
being  probably  not  less  than  20  per  cent.,  it  would  appear  that  rheu- 
matic heredity  has  a  certain  but  not  a  high  degree  of  importance  in  its 
association  with  chorea  per  se.  The  connexion  of  rheumatism  with 
chorea  may  well  be  more  extensive  than  statistics  can  show,  for  un- 
doubtedly rheumatism  may  follow  long  after  chorea,  and  early  rheu- 
matism may  escape  notice;  but,  from  the  above-given  and  subsequent 
reasons,  the  causative  role  of  rheumatism  itself  seems  to  be  strictly 
subordinate  to  certain  nervous  conditions  essential  to  the  production  of 
chorea.  There  is  no  clinical  difference  between  the  chorea  of  rheumatic 
and  non-rheumatic   subjects   other   than   the   permanent   heart-disease 


CHOREA.  301 

which  so  often  marks  the  rheumatic  class.  Hence  it  is  clear  that  there 
can  be  no  ultimate  explanation  of  chorea  in  the  fact  of  its  frequent 
alliance  with  rheumatism ;  and  it  must  be  remembered  that,  while  some 
choreics  are  rheumatic,  a  very  small  proportion  of  rheumatics  become 
choreic.  Doubtless  rheumatism  is  not  infrequently,  though  in  less  than 
10  per  cent,  of  my  own  cases,  the  immediate  excitant  or  antecedent 
of  chorea ;  and  it  may  be  that  an  hereditary  proclivity  to  rheumatism 
may  favour  the  development  of  the  disorder.  An  enormous  majority 
of  the  cases  of  definite  heart-disease  with  chorea  are  found  in  rheumatic 
subjects  and  are  mostly  subsequent  to  unquestionable  attacks  of  rheu- 
matism :  and  it  seems  to  me  at  least  probable  that  the  valvulitis  often, 
though  by  no  means  always,  found  in  cases  dying  with  chorea  is  of 
rheumatic  origin  albeit  undiscovered.  How  rheumatism  acts  as  favour- 
ing or  exciting  the  nervous  disorder  which  is  chorea  Ave  do  not  know. 
Sturges  has  suggested,  and  I  have  seen  some  cases  in  point,  that  the 
pain  of  rheumatism  may  be  the  immediate  excitant  of  a  chorea  which 
follows  directly  on  acute  attacks,  but  this  hypothesis  will  not  go  far. 
"We  know,  however,  that,  although  the  pathology  of  rheumatism  is  still 
obscure,  its  concurrence  or  association  with  chorea  is  by  no  means  its 
only  alliance  with  nervous  disorder ;  and  we  may  reasonably  believe  that 
the  true  nexus  between  rheumatism  and  chorea,  which  is  plainly  observ- 
able in  but  a  small  minority  of  choreics,  is  probably  to  be  found  in  some 
ancestral  nervous  disorder  common  to  both  complaints. 

In  most  cases  of  chorea  there  is  at  some  period  Heart-affection  of 
some  kind,  consisting  of  either  cardiac  murmurs,  mostly  systolic  and 
apical,  altered  or  reduplicated  sounds,  or  irregularity  in  force  or  rhythm 
of  the  heartbeats  ;  and  in  a  certain  number  there  is  clinical  evidence  of 
permanent  heart-disease.  In  in  out  of  156  cases,  personally  observed 
by  myself  and  by  others  as  well,  and  all  available  for  reference  on  these 
points,  I  found  one  or  more  of  the  above-mentioned  phenomena.  It 
is  especially  the  question  of  the  permanency  of  cardiac  murmurs  in 
chorea  and  of  their  relation  to  endocarditis  and  rheumatism  that  is 
here  important.  Apex  murmurs,  generally  systolic  only,  but  sometimes 
"  prsesystolic  "  or  both,  and  in  a  few  cases  accompanied  by  aortic  diastolic 
murmurs,  were  observed  in  80  cases ;  these  systolic  murmurs  were  often 
very  soft,  variable  and  evanescent,  altered  by  position,  or  accompanied 
by  a  basic  murmur,  and  disappeared  before  the  patient's  discharge.  In 
34  out  of  these  80  cases  rheumatism  was  noted  as  having  occurred,  some 
few  of  them,  however,  being  very  doubtfully  rheumatic.  The  murmur 
was  persistent  on  discharge  in  25  of  the  34,  and  disappeared  in  4,  the 
notes  of  the  remaining  5  being  deficient  on  this  point.  All  the  diastolic 
murmurs  are  included  in  these  25  persistent  cases. 

Of  the  remaining  46  cases  of  apical  murmur  without  history  or  sign 


302  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

of  rheumatism,  26  were  discharged  without  any  abnormal  heart-signs, 
1 2  with  both  murmur  and  movements,  1  died  with  a  structurally  healthy 
mitral  valve  as  demonstrated  post-mortem,  in  2  the  notes  are  silent  as 
to  murmur  on  discharge,  while  in  5  the  murmur  remained  when  the 
patients  left  hospital  free  from  all  movements.  In  2  of  these  5  cases 
there  was  a  presystolic  murmur  as  well  as  a  systolic,  indicating  a  pro- 
bability of  valvulitis  ;  but  in  none  was  there  any  further  sign  or  symptom. 
As  an  important  supplement  to  these  observations,  showing  the  very 
great  preponderance  of  rheumatism  in  the  history  of  cases  discharged 
well  with  murmurs,  I  will  shortly  recount  the  results  of  an  examination, 
by  Dr.  Hastings  and  myself,  of  44  patients  who  had  chorea  in  my  wards 
at  periods  varying  from  two  to  twelve  years  previously.  Although  several 
of  these  were  not  among  the  number  of  my  fully  reported  cases,  having 
been  imperfectly  noted  or,  in  a  few  instances,  altogether  omitted  from 
the  case-books,  the  lesson  taught  is  sufficiently  striking.  Of  the  44 
patients  thus  examined  18  had  murmurs,  mostly  apical  alone,  and  13 
of  these  had  had  rheumatism.  In  7  of  these  rheumatic  cases  the  heart- 
disease  had  been  noted  on  discharge  from  hospital,  in  2  others  the 
acute  rheumatism  had  taken  place  after  discharge,  and  in  the  rest  a 
murmur  on  discharge  was  not  mentioned  but,  being  previously  noted,  was 
probably  present.  In  the  remaining  26  the  heart  was  normal  both  as  to 
size  and  sounds.  Of  these,  three  had  had  rheumatism  certainly,  and  two 
doubtfully  ;  and  ten  more  were  found  noted  in  the  books  as  having  had 
systolic  apex  murmurs  or  irregular  heart-action.  Thus  out  of  16,  or 
possibly  18,  cases  with  rheumatism  there  was  persistent  murmur  in  13, 
accompanied  in  nearly  all  by  well-marked  signs  of  heart-disease,  while 
in  26  cases  without  any  evidence  of  rheumatism  there  were  but  5  with 
murmurs,  two  of  which,  though  apical  in  position,  were  accompanied  by 
loud  venous  humming  and  marked  anaemia.  In  the  third,  aged  n, 
examined  two  years  after  a  single  attack,  the  murmur  was  systolic  and 
apical,  and  unaccompanied  by  any  further  sign  or  symptom  of  heart- 
disease  ;  hi  the  fourth,  the  murmur  heard  at  the  lower  part  of  the  sternum 
was  diastolic  in  time  (the  aortic  second  sound  being  still  heard  at  the 
base),  and,  being  accompanied  by  a  loud  humming  and  arrested  by  pres- 
sure at  the  root  of  the  neck,  was  deemed  to  be  of  venous  origin ;  and  in 
the  fifth  case,  aged  18,  examined  five  years  after  a  third  attack  of  chorea, 
there  was  a  double  mitral  murmur  with  some  cardiac  enlargement.  A 
careful  study  of  these  apparently  non-rheumatic  cases,  10  in  all  out  of 
the  two  sets  of  observations,  will  show  that  not  more,  and  possibly  several 
less,  than  7  seem  to  be  referable  to  organic  heart-disease ;  and  the  whole 
series  of  cases  abundantly  indicates  that  permanent  heart-disease  is  rarely, 
even  in  appearance,  the  result  of  chorea  per  se. 

Subtracting  from  my  list  of  156  cases  above-mentioned  the  80  with 


CHOREA.  303 

apical  murmurs,  there  remain  45  with  normal  hearts  and  31  with  re- 
duplicated or  altered  sounds,  irregular  action,  basic  murmur  or  venous 
humming,  about  two-thirds  of  these  last  leaving  hospital  without  abnor- 
mality. Both  of  these  latter  classes  contain  several  cases  with  a  history 
of  previous  rheumatism.  I  would  add,  lastly,  that  in  the  178  West- 
minster cases,  summarised  by  the  registrars,  there  were  29  of  mitral 
murmurs,  constant  while  under  observation,  of  which  16  had  suffered 
from  definite  acute  rheumatism ;  while  in  7  7  there  were  varying  or  occa- 
sional apex  murmurs  quite  disappearing  before  the  patient's  discharge. 

Seeing,  then,  that  permanent  heart-disease  in  choreic  patients  is  in 
far  the  largest  number  of  cases  unquestionably  rheumatic,  and  bearing  in 
mind  that  rheumatism  or  other  disease  sometimes  escapes  observation  in 
childhood,  it  is  at  least  very  probable  that  such  heart-disease  is  either 
rheumatic  in  origin  or  due  to  some  other  cause  of  valvulitis  apart  from 
the  chorea.     But  here  a  certain  difficulty  meets  us  in  the  occasional 
presence  of  small  vegetations  on  the  edges  of  the  mitral  valve  in  patients 
dying  with  chorea,  without  history  of  rheumatic  symptoms  of  heart- 
disease  or  even  observed  murmurs,  of  which  one  case  occurred  in  my 
wards  at  "Westminster  in  May  189 1,  and  has  been  quoted  by  Dr.  Sturges 1 
in  connexion  with  this  subject.     But  it  seems  as  reasonable  to  refer  this 
valvular  affection,  found  in  some  of  those  exceptional  cases  which  die, 
either  to  the  well-accredited  rheumatic  cause  (albeit  undiscovered)  or  to 
some  other  morbid  process,  as  to  contend  that  chorea  has  an  endocarditis 
of  its  own  apart  from  rheumatism.     Chorea,  it  must  be  remembered, 
nearly  always  recovers ;  and,  as  we  have  seen,  permanent  heart-disease 
very  rarely  follows  on  any  but  definitely  rheumatic  cases.     It  is  also  true, 
although  frequently  forgotten,  that  healthy  valves  are  not  seldom  found 
post-mortem  after  death  with  chorea.    Of  this  I  have  seen  four  examples, 
in  three  of  which  well-marked  systolic  murmurs  were  more  or  less  per- 
sistent until  death.     I  do  not  discuss  the  possible  or,  it  may  be,  probable 
theory   that   the  fine  valvular  vegetations  found  in  presumably   non- 
rheumatic  chorea  are  caused  by  the  mechanical  deposit  of  fibrin,  for  such 
an  hypothesis  can  neither  be  demonstrated  nor  disproved     We  certainly 
know  that  rheumatic  endocarditis  may  occur  without  murmur,  and  there 
is  good  reason  to  believe  that  ordinary  valvulitis  may  occasionally  dis- 
appear ;  but  it  remains  true  that  such  a  frequent  recovery  as  must  be 
involved  in  the  theory  of  the  constantly  endocarditic  origin  of  choreic 
murmurs  is  not  in  accord  with  clinical  and  pathological  knowledge.     I 
woidd  further  urge,  not  only  that  irregularity  of  the  heart-beats  is  much 
more  marked  in  simple  chorea  than  in  at  least  the  early  stages  of  organic 
mitral  disease  in  children,  but  also  that  the  invariable  absence  of  the 
signs  of  aortic  regurgitation  in  non-rheumatic  cases,  however  the  heart 
1  See  International  Journal  of  the  Medical  Sciences,  Dec.  1S91. 


304  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

may  be  otherwise  affected,  tells  considerably  against  the  endocarditic 
theory  of  the  ordinary  mitral  trouble  in  chorea. 

Many  of  the  murmurs  in  non-rheumatic  chorea  are  probably  of 
dynamic  origin,  and  connected  with  faulty  innervation  of  the  nervo- 
muscular  apparatus  of  the  heart  and  valves ;  while  some  may  be  referable, 
in  part,  to  temporary  cardiac  dilatation. 

The  morbid  anatomy  of  cases  dying  with  chorea  throws  but  little 
light  on  pathogeny,  as  might  be  expected  from  the  prevalent  tendency 
of  the  disease  to  recovery ;  and  it  is  clear  that  no  permanent  lesion  can 
be  the  true  cause  of  the  phenomena  to  be  explained.  Death  with  or 
from  chorea  below  the  age  of  puberty  is  very  uncommon,  and  in  boys 
extremely  rare.  Great  mental  excitement  or  other  impairment  is  the  rule 
in  cases  dying  with  otherwise  apparently  simple  chorea,  and  acute  rheu- 
matism figures  largely  in  the  fatal  cases.  I  saw  a  case,  however,  many 
years  ago  in  a  child  of  five  where  the  chorea  was  neither  severe  nor 
rheumatic,  but  where  there  was  an  apex  murmur.  Death  followed  on  a 
short  attack  of  vomiting,  with  violent  palpitation  and  epigastric  pain ; 
but  post  mortem  the  heart  and  all  other  organs  appeared  perfectly  normal. 

After  consideration  of  much  that  I  have  read  and  something  that  I 
have  seen  regarding  the  post-mortem  appearance  of  the  nerve-centres, 
I  believe  that  morbid  anatomy  has  contributed  little  of  importance 
towards  aetiology,  excepting  a  considerable  amount  of  evidence  of  either 
recent  or  long-standing  hyperemia  of  the  brain  and,  perhaps,  of  the  cord ; 
and  that  we  may  reject  the  theories  of  neurologists  generally  on  this 
point,  including  one  of  the  latest  which  suggests  sclerosis  of  the  nerve- 
centres  as  explanatory  of  choreic  phenomena.  The  fact  of  changes  in 
the  medulla  and  other  parts,  due  to  hyperaemia,  as  shown  in  some  cases 
by  the  enlargement  of  vessels  and  a  marked  cellular  accumulation  in  the 
perivascular  spaces,  may  indeed  be  referred  to  vaso-motor  origin ;  but  it  is 
clear  from  the  whole  natural  history  of  the  disorder  that  such  appearances 
are  secondary,  and  that  a  wider  cause  must  be  sought  for  the  explanation 
of  both  the  vaso-motor  paralysis  and  all  the  varied  phenomena  of  the 
disease.1  Of  the  heart-changes  found  after  death  with  chorea  I  have 
already  spoken.     They  do  not  appear  to  have  any  connexion  with  the 

1  Since  writing  the  above  I  have  seen  Dr.  Charlewood  Turner's  valuable  paper 
(in  the  Trans.  Path.  Soc.  of  London,  1892),  describing  lesions  of  some  of  the  large 
pyramidal  cells  in  the  deeper  layers  of  the  cerebral  cortex  in  the  Rolandic  region. 
The  lesions,  observed  by  him  in  five  cases  dying  with  chorea,  consisted  in  marked 
cedematous  swelling.  Dr.  Turner  argues  that  such  lesions,  being  presumably  recover- 
able unless  in  their  highest  grade,  are  in  accordance  both  with  the  clinical  fact  of 
the  uncontrolled  voluntary  movements  of  chorea  (whether  temporary  or  indefinitely 
persistent),  and  also,  as  indicative  of  nutritive  defect,  with  the  pathogenic  conditions 
with  which  the  occurrence  of  chorea  is  associated.  Dr.  Turner  admits  that  these 
lesions  in  his  cases  were  probably  in  part  due  to  the  exhaustion  of  the  patients  in  the 


CHOREA.  305 

mortality  of  the  disease  and  may  be  absent  in  fatal  cases  of  otherwise 
typical  character. 

The  origin  of  chorea  is  probably  to  some  extent  explicable  by  the 
unstable  condition  of  the  developing  motor  nerve  centres  in  childhood, 
and  the  natural  history  of  the  disease  shows  that  it  makes  its  usual 
appearance  at  the  very  time  and  in  the  very  manner  that  we  might 
expect  from  the  various  stresses  and  disturbances  incident  on  these 
centres  before  they  are  duly  organised  for  controlling  muscular  move- 
ments. The  disorder  affects  first  and  especially  those  parts  of  the  body 
which  mostly  lack  due  control,  at  a  time  when  that  control  is  more 
and  more  in  requisition ;  and  its  subjects  are  mainly  girls  and  little  boys 
in  large  and  crowded  towns,  whose  nervous  systems  are  unavoidably 
exposed  to  the  many  rude  buffets  which  are  the  heritage  of  poverty  with 
all  its  negative  and  positive  evils.  This  enormously  preponderating 
incidence  of  chorea  on  the  children  of  the  poor,  with  its  bearing  on  both 
aetiology  and  treatment,  must  never  be  lost  sight  of. 

It  has  been  fully  shown  by  Sturges  that  the  uncontrolled  movements 
of  many  fidgety  children  are  of  the  same  pattern  as  those  of  established 
chorea;  and  it  may  be  said  that  an  exaggeration  of  what  may  be 
called  a  physiological  neurosis  of  childhood  is  the  true  neurosis  which 
makes  chorea  possible.  For  the  production  of  the  marked  clinical  dis- 
order such  a  basis  is  necessary,  as  well  as  some  exciting  cause  for  its 
special  display,  such  exciting  cause  being  definite  and  powerful  in  inverse 
proportion  to  the  grade  of  the  neurosis.  Children,  indeed,  are  all  poten- 
tially choreic,  even  as  all  adults  are  potentially  hysterical. 

There  is  abundant  evidence  of  various  nervous  disorders  in  the 
persons  and  families  of  choreic  children,  and  the  older  the  child  the 
more  prominent  this  relationship  becomes.  The  frequent  emotional 
symptoms  already  mentioned  illustrate  this  point,  and  well-marked 
migraine  and  less  special  forms  of  headache  are  exceedingly  common. 
Out  of  162  cases,  excluding  for  the  moment  42  of  them  presently  to 
be  quoted  in  connexion  with  the  excitants  of  chorea,  I  find  at  least 
39  who  were  spontaneously  stated  by  the  parents  to  be  always  ex- 
ceptionally "nervous,"  "excitable"  or  "irritable;"  several  subject  to 
night  terrors;  and  many  hysterical.  In  30  histories  from  this  list  of 
choreics  I  find  a  definite  note  of  epilepsy,  insanity,  chorea  or  marked 
hysteria  in  one  or  more  members  of  the  family,  and  in  all  but  four 
instances  (of  grandfather,  aunt  and  uncles)  the  affected  relatives  were 

moribund  state  ;  but  a  careful  consideration  of  his  observations  and  reasoning  seems 
to  establish  a  great  likelihood  that  future  research  in  this  direction  will  prove  that 
such  lesions  as  he  describes  are  necessary  for  the  production  of  those  choreic  move- 
ment-symptoms which  are  referable  to  disturbance  in  the  Rolandic  (or  so-called 
"motor")  region  of  the  cerebral  cortex. 

U 


306  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

father,  mother,  brother  or  sister.  Chorea  was  noted  in  13  families 
(thrice  in  the  mother  and  once  in  the  father),  epilepsy  in  8,  and 
insanity  in  5.  In  many  of  my  cases  the  family  histories  were  taken 
without  any  reference  to  nervous  disorder.  It  may  be  concluded,  there- 
fore, that  nervous  heredity  probably  plays  a  much  more  important  part 
among  the  antecedents  of  chorea  than  is  shown  by  these  statistics, 
striking  though  they  are. 

As  a  definitely  exciting  cause  of  choreic  attacks,  nervous  disturbance, 
evidenced  by  great  emotion  or  distinct  fright  preceding  chorea  at  periods 
varying  from  a  few  hours  to  two  days,  is  noted  in  detail  in  42  out  of 
162  cases.  I  have  particularised  26  of  these  (belonging  to  a  series  then 
numbering  105)  in  vol.  i.  of  the  "Westminster  Hospital  Reports  (1886), 
and  cannot  dwell  longer  here  on  this  important  point.  Besides  these  I 
have  several  more  recent  cases,  and  some  which  illustrate  Sturges'  obser- 
vations of  the  origin  of  movement  in  the  limb  or  limbs  which  have  been 
the  subjects  of  fatigue,  injury,  or  some  other  impression  causing  fright : 
as,  for  instance,  in  a  leg  after  treading  on  a  cat,  in  a  limb  which  has  been 
struck,  or  in  hands  overworked  with  writing  or  sewing. 

It  is  the  custom  of  many  authorities  on  this  subject,  and  especially  of 
some  who  hold  the  almost  exclusively  rheumatic  pathogeny  of  chorea,  to 
neglect,  deride  or  exclude  all  evidence  or  allegations  of  nervous  excitants 
as  vague  and  unappreciable  ;  but  I  would  urge  from  a  study  of  my  own 
cases,  apart  from  the  experienced  statements  of  Sturges  and  other  weighty 
authorities,  that  there  is  a  positive  and  undeniable  proof  of  definite  nervous 
disorder,  both  personal  and  hereditary,  as  showing  predisposition,  and 
of  definite  nervous  disturbance  as  an  excitant  to  chorea,  in  a  far  greater 
number  of  cases  than  there  is  evidence  of  either  family  or  immediate 
rheumatism.  It  must,  moreover,  be  clear  to  any  one  who  reflects  on  this 
matter  that  many  hereditary  cases,  especially  of  insanity  and  epilepsy, 
may  be  concealed;  and  that,  from  the  nature  of  things,  and  notably 
among  the  poor,  large  numbers  of  efficient  causes  of  fright  and  other 
nervous  disturbance  in  childhood  must  necessarily  escape  notice.  Rheu- 
matism, as  we  have  seen,  enhances  the  neurosis  of  chorea,  and  certainly 
excites  the  attacks  in  many  instances ;  and  the  two  affections  may  have 
neural  relationships  of  old  ancestral  date.  It  must,  however,  be  remem- 
bered that  very  often  a  definite  nervous  shock  immediately  precedes 
chorea  in  cases  which  at  some  previous  time  have  had  an  attack  of 
rheumatism. 

In  closing  these  remarks  on  aetiology  I  must  refer  to  an  important 
instance  of  the  varying  topical  distribution  of  chorea,  which  was  given 
by  Dr.  Ranke  of  Munich  at  the  International  Medical  Congress  held 
in  London  in  188 1.  Out  of  40,723  children,  seen  by  him  during 
fourteen  years,  there  were  only  19  cases  of  chorea.     Dr.  Ranke  then 


CHOREA.  30/ 

informed  me  that  there  was  no  lack  of  rheumatism  among  his  patients. 
It  would  thus  appear  that  it  is  in  other  and  more  complex  condi- 
tions that  an  explanation  must  be  sought  of  the  frequency  or  rarity 
of  chorea  in  different  places. 

Of  prognosis  in  chorea  something  has  already  been  said  incidentally. 
The  most  suddenly  beginning  and  severest  cases  which  soon  reach  their 
height  are  by  no  means  the  most  protracted.  When  properly  treated, 
indeed,  they  are  in  my  experience  considerably  below  the  average  in 
duration.  I  have  repeatedly  seen  patients,  who  soon  required  padded 
beds  and  very  careful  attention,  recovering  completely  in  three  weeks  or 
less.  The  more  chronic  the  case  and  the  less  simply  motor  it  appears  to 
be,  the  more  doubtful  is  the  prognosis  as  to  duration  or  ultimately  perfect 
recovery ;  and  the  history  and  nervous  concomitants  of  each  individual 
case  are  of  great  weight  in  respect  to  the  probability  of  recurrence.  The 
average  duration  of  chorea  is  not  a  question  of  much  importance,  for 
in  many  cases  its  onset  is  gradual  and  its  date  unnoted.  Excluding 
some  exceptionally  chronic  cases,  however,  I  am  inclined  to  set  down 
the  average  period  from  the  first  noticed  movements  to  their  complete 
cessation  as  about  eleven  weeks ;  but  with  proper  treatment  from  the 
beginning  this  might  possibly  be  much  less.  Very  chronic  cases  are 
usually  slight;  and  in  those  which  last  for  years  the  movements  are 
generally  limited,  and  may  frequently  be  confined  to  the  hand  or  face 
alone  or  to  a  single  group  of  muscles.  I  have  seen  two  cases,  as  the 
remnants  of  chorea,  of  very  obstinate  but  ultimately  curable  spasmodic 
movements  of  the  sterno-mastoid  or  other  neck-muscles.  One  of  these 
had  lasted  nearly  five  years.  Control  over  the  tongue,  as  shown  by  the 
power  of  retracting  it  steadily  and  slowly,  is  usually  regained  before 
facial  and  hand  movements  cease,  and  is  generally  a  herald  of  good 
recovery ;  but  there  are  many  slight  cases  where  the  tongue  is  but  little 
or  not  at  all  involved. 

Chorea  is  much  influenced  by  treatment,  the  right  direction  of  which 
is  already  indicated  by  much  that  I  have  said.  The  most  complete  rest, 
both  of  body  and  mind,  must  be  enjoined  or  encouraged,  and  the  patients 
should  in  all  cases  be  kept  in  bed  until  the  movements  have  nearly 
ceased.  In  severe  cases  which  show  no  signs  of  improvement,  and 
especially  when  complicated  or  attended  by  much  mental  disturbance, 
absolute  quiet  and  comparative  darkness  are,  I  believe,  strongly  advisable ; 
and  the  child  should  be  visited  by  none  but  its  attendants.  In  ordinary 
cases,  however,  the  quiet  routine  of  treatment  in  a  ward  for  children 
only  seems  very  beneficial,  affording  occasions  for  both  companionship 
and  amusement.  From  a  comparison  of  cases  treated  over  many  years 
at  Shadwell  with  those  at  Westminster  I  find  that  nearly  two-thirds  of 
the  former  leave  hospital  perfectly  recovered,  but  scarcely  more  than 


308  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

one-third  of  the  latter.  This  is  not  to  he  accounted  for  hy  difference 
of  period  of  stay  in  hospital  or  of  medical  treatment,  hut  is  prohahly 
due  to  all  of  the  Westminster  cases  having  heen  treated,  until  recently, 
in  wards  with  adult  patients,  and  thus  more  variously  disturhed  than 
at  Shadwell. 

Choreic  cases  should  not  he  placed  within  sight  of  one  another ;  for, 
although  I  have  never  seen  an  instance  of  chorea  arising  from  imitation, 
I  am  sure,  from  experience  of  some  cases  of  recurrence  after  such  juxta- 
position and  of  many  more  of  strikingly  rapid  improvement  on  removal 
from  a  choreic  neighbour,  that  the  nervous  effects  of  chorea  upon 
chorea  are  had.  In  all  severe  cases  injury  should  he  prevented  hy 
padding  the  bed;  hut  coercion  of  the  limhs  should  only  he  practised, 
as  a  rule,  in  cases  where  the  child  might  otherwise  hurt  itself.  As 
complete  freedom  as  possible,  physical  as  well  as  mental,  is  indeed  ever 
to  be  aimed  at  in  the  treatment  of  chorea.  In  a  few  cases,  however, 
Dr.  Sturges  has  obtained  a  good  result  from  wrapping  the  child  in  a 
sheet,  the  sufferers  expressing  a  feeling  of  relief  in  such  confinement  of 
their  limbs.  I  have  myself  tried  this  method  with  success  in  one  or 
two  instances ;  but,  as  Dr.  Sturges  insists,  the  child  must  always  be  con- 
sulted before  the  movements  are  thus  restrained.  Nasal  feeding  must 
be  employed  when  there  is  dysphagia,  and  all  care  taken  to  keep  up 
nutrition  whenever  it  seems  to  fail.  Constipation,  which  is  even  more 
frequent  in  choreics  than  in  most  patients  confined  to  bed,  should  be 
corrected  by  occasional  enemas  or  aperients ;  and  disturbed  sleep  or 
sleeplessness  must  be  combated.  If  warmth  to  the  feet,  feeding  at 
frequent  intervals,  quiet  and  darkness  fail,  I  give  wine  or  brandy  in 
varying  doses,  opium,  a  combination  of  chloral  and  ammonium  bromide, 
or  sulphonal.  This  last  drug  is  very  useful ;  but  I  can  say  from  expe- 
rience that  it  should  be  given  with  caution,  always  under  observation, 
and  never  pushed  so  far  as  to  produce  continuous  sleep.  One  dose  in  the 
twenty-four  hours  of  about  10  to  15  grains  for  a  child  of  ten  is  probably 
enough.  The  drug  takes  long  to  dissolve  in  the  body,  and  is  apparently 
cumulative  in  action.  "When  the  nightly  sleep  is  good,  narcotic  and 
paralysing  drugs  should,  I  think,  never  be  given.  Formerly  I  have 
often  tried  these  methods,  but  never  with  good,  and  sometimes  with  evil, 
results ;  and,  having  not  seldom  given  conium  in  doses  which  produced 
their  physiological  effects,  I  am  convinced  that  it  is  much  worse  than 
useless. 

In  most  cases  the  child's  attention  should  be  directed  away  from  its 
movements ;  and  as  soon  as  any  improvement  is  shown,  but  not  before, 
spontaneous  attempts  at  definite  use  of  the  hands  should  be  encouraged. 
When  voluntary  control  lessens  the  movements,  regulated  use,  as  in  writ- 
ing, knitting  or  needlework,  may  be  practised  for  a  short  time  daily.     In 


CHOREA.  309 

some  mild  cases,  where  improvement  lingers  during  rest  in  bed,  I  have 
found  it  well  to  allow  the  children  to  sit  up  or  even  walk  about.  The 
effect  of  this  change  must,  however,  be  carefully  watched. 

As  soon  as  it  is  deemed  advisable  to  get  the  patient  up,  a  change 
of  scene  is  often  of  great  benefit.  The  child  should  be  sent  into  the 
country  to  lead  an  unexciting  life  under  the  influences  of  as  much  fresh 
air  and  sunlight  as  possible,  with  gentle  and  regulated  exercise. 

Although  many  cases  are  apparently  in  good  health,  many  more  are  in 
need  of  both  natural  and  medicinal  nervine  tonics ;  and  it  is  in  these  that 
drug-treatment  is  often  of  great  service.  I  have  had  no  doubt  for  many 
years  now,  having  previously  persevered  with  many  medicines  indiscri- 
minately, that  the  numerous  cures  by  drugs  and  especially  by  arsenic, 
reported  from  time  to  time  in  the  journals,  are  to  be  fully  explained  in  this 
way ;  and  I  am  wholly  in  accord  with  Sturges  when  he  says  that  arsenic 
and  other  medicinal  tonics  are  indicated  not  by  the  chorea  itself  but  by 
its  many  associated  weaknesses.  Among  these  anaemia  is  prominent ; 
and,  believing  in  the  very  great  value  of  arsenic  in  many  cases  of  this 
affection,  I  frequently  give  it  in  chorea  when  it  is  thus  or  otherwise 
indicated.  At  the  same  time  I  am  well  convinced  that  in  a  very 
large  number  of  cases  of  chorea  there  is  neither  promise  nor  potency 
of  cure  by  any  known  drug.  I  have  tried  arsenic,  as  the  best  accredited 
medicine,  in  many  obstinate  cases,  and  in  large  and  rapidly  increased 
doses;  but  have  never  found  improvement  except  when  other  condi- 
tions were  changed  as  well.  As  regards  the  use  of  arsenic,  I  believe  that 
larger  doses  than  from  3  to  5  minims  of  the  "liquor,"  thrice  daily,  need 
never  be  given ;  and  that  in  children,  whether  choreic  or  not,  there  is 
quite  as  much  susceptibility  to  poisoning  when  the  drug  is  pushed  as  in 
the  case  of  adults.  Cod-liver  oil  and  iron  are  also  most  useful  tonics. 
In  some  cases,  especially  of  long  standing,  indigestion  may  require  treat- 
ment by  regulated  diet  and  appropriate  medicines. 

In  the  paralytic  cases  the  greatest  care  should  be  observed  in  moving 
the  patients,  for  the  heart  is  often  markedly  feeble ;  unremitting  attention 
must  be  given  to  feeding,  the  nasal  tube  being  used  if  need  be ;  and 
frequent  small  doses  of  alcohol  may  be  indispensable. 


3  I O  DISORDERS  OF  THE  NERVOUS  SYSTEM. 


CHAPTER  VI. 

HYSTERIA  AND  FUNCTIONAL  NERVOUS  DISORDER. 

Although  many  systematic,  and  more  especially  foreign,  writers  on 
nervous  disorders  have  fully  recognised  the  frequency  of  hysterical 
phenomena  in  childhood,  this  subject  has  been  hut  slightly  glanced  at  or 
altogether  ignored  by  the  authors  of  most  works  on  disease  in  children. 
The  admirable  lecture,  however,  on  hysteria  in  Professor  Henoch's  work, 
and  the  comprehensive  article,  richly  illustrated  by  cases  and  quotations 
from  many  sources,  by  Dr.  C.  K.  Mills  in  Keating's  Gyclopcedia  of  the 
Diseases  of  Children  leave  little  to  be  desired  by  the  clinical  student. 
In  this  country  Dr.  Wilks,  in  his  lectures  on  Diseases  of  the  Nervous 
System,  long  ago  called  attention  to  hysteria  in  young  boys  as  well  as 
girls ;  and  interesting  cases  have  from  time  to  time  been  published  by 
different  observers.  A  compendious  but  very  practical  account  is  given 
by  Messrs.  Ashby  and  Wright  in  their  text-book  of  the  Diseases  of 
Children. 

I  shall  mainly  devote  this  chapter  to  a  few  cases,  culled  from  large 
numbers  in  my  note-books,  in  illustration  of  the  chief  varieties  of  hys- 
terical and  other  phenomena  in  children  under  the  age  of  fourteen ; 
omitting,  perforce,  the  consideration  of  multiform  nervous  disorders 
incident  on  the  periods  of  puberty  and  adolescence.  Being  precluded 
by  limits  of  space  from  attempting  to  discuss  or  define  hysteria,  I  would 
refer  the  reader  for  my  own  views  on  the  subject  to  the  article  under 
this  heading  in  Tuke's  Dictionary  of  Psychological  Medicine  ;  and  would 
only  state  here  that  I  construe  the  term  widely  as  signifying  a  neurosis 
largely  due  to  hereditary  constitution,  regarding  the  various  concrete 
expressions  of  the  disorder  as  the  result  of  multiform  excitants  acting  on 
this  vulnerable  nervous  material.  In  the  case  of  children  fear  and  pain 
rank  high  among  the  exciting  causes  of  hysterical  display.  It  must  be 
remembered  that  hysteria  is  a  psychosis  as  well  as  a  neurosis  :  that  some 
degree  of  mental  disorder,  evinced  in  the  sphere  of  feeling  rather  than  of 
intellect,  colours  and  underlies  all  its  phenomena,  predominantly  physical 
in  expression  though  they  often  are.  We  thus  both  expect  and  find 
two  characteristics  in  the  hysteria  of  early  childhood.  Owing  to  the 
still  imperfect  and  at  the  same  time  rapid  development  of  the  higher 
nervous  centres,  whose  action  is  associated  with  the  control  of  the 
emotions  and  of  sensory  and  motor  action  as  well,  less  obvious  external 
stresses  upset  control  and  produce  hysterical  phenomena  in  the  child 


HYSTERIA  AND  FUNCTIONAL  NERVOUS  DISORDER.       3  I  I 

than  in  the  adult.  By  reason,  again,  of  the  less  perfect  development  of  the 
higher  cerebral  functions,  the  less  complex  are  the  relations  of  the  child 
with  the  external  world ;  and  the  less,  in  consequence,  is  the  sphere, 
and  the  fewer  are  the  varieties,  of  possible  aberration.  Although,  as 
we  shall  see,  hysterical  phenomena,  comparable  with  many  that  are 
seen  in  adults,  whether  prominently  mental,  sensory,  or  motor  in  ex- 
pression, are  frequently  met  with  in  childhood,  yet  their  character  is 
less  protean  than  in  later  life,  being  limited  by  the  child's  stage  of 
development.  As  soon,  however,  as  cerebral  development  has  advanced 
so  far  as  to  render  mental  action  evident,  the  time  of  possible  hysteria 
has  arrived.  I  would  mention  here  once  for  all,  with  respect  to  the 
neurotic  relationships  of  hysteria,  that  many  cases  show  a  large  proportion 
of  family  histories  of  insanity,  epilepsy,  chorea  and  hysteria  itself ;  and 
that  in  hysterics  there  is  not  seldom  a  history  of  infantile  convulsions. 
A  considerable  number  of  choreics  are  markedly  hysterical,  and  a  history 
of  definite  epileptic  fits  is,  in  my  experience,  very  common  with  hysterical 
children. 

As  in  adults,  so  in  children,  hysteria  may  show  itself  mainly  in  psychical 
aberration ;  or  its  most  prominent  features  may  be  motor  disturbance, 
either  spasmodic  or  paralytic,  sensory  disturbance  in  the  form  of  either 
anaesthesia,  hypersesthesia  or  pain,  or  some  other  disorders  of  function. 
In  most  these  various  elements  are,  some  or  all  of  them,  inextricably 
blended ;  and  the  psychical  factor,  however  latent  it  may  be,  must  be 
thought  of  as  always  present.  For  practical  purposes,  however,  I  shall 
dwell  shortly  on  the  mental  aspect  of  hysteria  before  giving  illustrations 
of  the  more  prominently  physical  expressions  of  the  disorder. 

The  cardinal  fact  in  the  psychopathy  of  hysteria  is  an  exaggerated 
self-consciousness  dependent  on  feeling  uncontrolled  by  intellect;  and 
we  know  that  even  in  the  normal  child  there  is  an  ample  supply  of  this 
material.  Besides  this,  evinced  in  many  vagaries  of  conduct,  there  is 
often  some  intellectual  disturbance  proper  as  well ;  but  the  chief  mental 
abnormality  is  evidenced  in  the  sphere  of  feeling,  and  mainly  by  ex- 
cessive impressionability  and  tumultuous  emotion  on  slight  excitation. 
In  close  association  with  this  are  phenomena  which  are  the  direct  results 
of  simulation  or  with  difficulty  distinguished  therefrom.  In  hysterical 
adults  of  both  sexes  we  are  all  familiar  with  the  frequent  coincidence  or 
alternation  of  clearly  involuntary  disorder  with  equally  certain  malinger- 
ing, and  outrageous,  or  practically  criminal,  conduct.  This  connexion  is 
not  seldom  seen  in  childhood ;  but  continuous  and  elaborate  hysterical 
display,  whether  mingled  or  not  with  imposture,  is  but  rarely  met  with 
in  young  children,  their  mental  development  being  generally  inadequate 
for  its  production.  The  following  case,  exceptional  in  so  young  a  child, 
will  serve  to  illustrate  this  and  other  points. 


3  I  2  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

A  girl  of  ten  was  admitted  complaining  of  headache  and  giddiness, 
stiffness  of  the  left  leg,  and  great  difficulty  in  walking,  from  which  she 
had  "been  suffering  for  several  months.  She  had  come  from  another 
hospital,  with  the  provisional  diagnosis'of  spastic  paralysis.  Two  years 
before  these  complaints  set  in  she  had  been  subject  to  occasional  fits 
which  were  seemingly  epileptic.  Her  left  leg  was  apparently  shorter, 
certainly  somewhat  smaller,  and  of  lower  temperature  than  the  right; 
the  knee-jerk  was  excessive,  and  there  was  marked  ankle-clonus.  On 
the  right  side  the  knee-jerk  was  brisk,  and  slight  ankle-clonus  was  obtain- 
able. The  gait  soon  became  much  worse,  the  left  leg  seeming  nearly 
an  inch  shorter  than  the  right.  On  examination,  this  apparent  shorten- 
ing was  found  by  measurement  to  be  due  to  tilting  of  the  pelvis,  and  at 
the  same  time  a  large  phantom  tumour  suddenly  appeared  in  the  abdo- 
men. The  left  lower  extremity  was  very  rigid.  It  was  then  decided,  in 
her  presence,  to  examine  her  under  chloroform.  A  week  later  this  was 
done,  upon  which  all  rigidity  and  apparent  shortening  disappeared,  and 
spine,  pelvis  and  limbs  were  found  to  be  quite  normal.  It  was  dis- 
covered, while  she  was  still  insensible,  that  her  nostrils  were  stuffed  with 
cotton- wool ;  this  device  to  avoid  the  effect  of  the  chloroform  having  been 
carried  out  by  herself  shortly  before  my  visit,  as  she  afterwards  confessed. 
All  the  symptoms  reappeared  before  she  fully  regained  consciousness ; 
but,  having  been  told  that  her  leg  was  cured,  she  rapidly  improved  and 
after  a  fortnight's  absolute  neglect  was  discharged  perfectly  well  in  every 
respect.  She  was  cured  partly  by  the  detection  of  her  trick  and  partly 
by  her  belief  in  the  treatment. 

In  the  especially  mental  class  of  hysterical  cases,  which  usually  implies 
a  markedly  bad  neurotic  heredity,  we  must  place  numerous  vagaries  of 
conduct,  and  excessive  and  apparently  causeless  emotional  display,  arising 
more  or  less  clearly  out  of  extreme  self-consciousness.  Frequent  results 
of  this  are  acts  of  destructiveness,  such  as  the  smashing  of  glass  and 
furniture ;  setting  fire  to  bedclothes,  curtains  &c. ;  self -injury,  especially 
in  the  form  of  scratching  the  skin ;  and  other  conduct  which  may  perhaps 
be  differentiated  from  insanity  only  by  greater  amenability  to  the  moral 
control  of  others,  by  the  temporary  nature  of  the  outbreaks,  and  by 
frequent  associations  with  sensory  or  motor  disorders  of  the  hysterical 
type.  Many  of  these  cases,  indeed,  are  on  or  within  the  border-line  of 
insanity ;  for  we  can  scarcely  class  otherwise  those  actions  of  arson, 
murder,  suicide  and  the  like  which  we  read  of  from  time  to  time  as 
committed  by  boys  and  girls. 

Typically  acute  maniacal  attacks,  usually  of  short  duration,  are  some- 
times seen  in  children  of  markedly  hysterical  temperament,  and,  with 
proper  care,  may  disappear  without  recurrence.  I  have  also  seen  some 
cases,  with  a  history  of  a  recent  fit  or  fits,  which  were  marked  by  eccentric 


HYSTERIA  AND  FUNCTIONAL  NERVOUS  DISORDER.       3  I  3 

conduct  of  various  kinds,  such  as  is  often  observed  in  the  post-epileptic 
conditions  of  adults.  A  not  uncommon  phenomenon  is  the  imitation  of 
the  noises  and  habits  of  animals  :  for  instance,  barking  like  a  dog  and 
biting  at  bystanders.  This  is  sometimes  seen  in  combination  with  spas- 
modic phenomena,  such  as  coughing  with  a  whoop,  or  "croupy"  and 
rapid  breathing ;  and  I  have  seen  several  cases  of  paroxysmal  attacks 
of  grunting  expiration,  lasting  many  hours,  in  children  with  marked 
mental  evidence  of  hysteria,  although  this  phenomenon  often  occurs  as 
the  most  prominent  symptom.  It  is  rare  to  find  well-marked  examples 
of  this  pre-eminently  mental  form  of  hysterical  display  in  young  children ; 
and  it  is  doubtless  during  a  year  or  two  before  puberty  that  the  worst 
cases  of  this  kind  occur.  In  such  cases,  too,  I  am  of  opinion  that  a 
markedly  bad  family  history  of  the  graver  neuroses  is  excessively 
frecpuent ;  and  several  that  I  have  met  with  have  suffered  notably  from 
infantile  convulsions.  The  hysteria  of  childhood  well  illustrates  the 
truth  that  the  less  obvious  the  exciting  cause  the  profounder  is  the 
fundamental  neurosis ;  many  of  the  attacks  which  we  are  considering 
being  almost,  if  not  quite,  inexplicable  by  their  immediate  conditions. 
The  following  case  is  a  good  example  of  this  form  of  hysterical  outbreak. 

A  boy  of  nine,  begotten  by  an  actually  intoxicated  father  who  had 
been  a  drunkard  from  his  youth,  was  violently  passionate  from  his 
infancy,  and  soon  developed  somnambulism.  His  schoolmaster  reported 
him  as  tractable  and  intelligent  but  very  restless.  Some  months  before 
admission  he  had  several  attacks  of  furious  and  apparently  causeless 
passion,  foaming  at  the  mouth  with  fixed  jaws  and  rapid  breathing. 
On  more  than  one  occasion  he  said  that  he  would  kill  his  brother.  In 
one  of  these  attacks  he  was  brought  to  the  hospital.  During  his  stay 
there  of  some  weeks  he  was  quiet  and  docile,  and  seemed  perfectly 
intelligent. 

The  next  case,  of  an  older  boy  nearly  fourteen,  open,  according  to  some, 
to  the  interpretation  of  malingering,  exemplifies  at  least  the  difficulty 
of  accurate  diagnosis.  He  had  no  bad  family  or  personal  history.  About 
a  year  before  admission  to  Shadwell  Hospital  he  complained  of  severe 
headache,  often  sleeping  almost  continuously  for  a  week,  with  much 
somniloquence,  and  appearing  quite  rational  in  the  intervals.  He  soon 
became  subject  to  attacks  of  "wildness,"  grinding  his  teeth,  swearing, 
and  smashing  furniture,  and  was  afterwards  apparently  unconscious  of 
what  he  had  done.  A  little  before  admission  prolonged  drowsiness 
was  broken  by  these  outbreaks  alone.  He  feared  solitude,  fancied  he 
saw  rats  and  mice,  and  frequently  screamed  with  terror.  In  his  sleep 
his  limbs  were  often  seen  to  twitch.  He  never  hurt  himself  nor  any 
one  else.  On  admission  he  appeared  healthy,  and  nothing  abnormal  was 
found  on  a  searching  examination.     While  in  hospital  for  a  fortnight  he 


314  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

had  no  symptoms.  Two  years  and  a  half  afterwards  he  came  to  me  as 
out-patient  at  Westminster  Hospital,  with  a  string  of  complaints  which  I 
at  once  deemed  imaginary.  I  did  not  recognise  him  until  he  subsequently 
told  me  that  he  had  been  at  Shadwell. 

Night  terrors  with  trembling  or  screaming,  and  with  or  without  definite 
hallucinations  described  by  the  patient,  are  very  common  in  hysterical 
children.  They  are,  however,  by  no  means  confined  to  this  class,  for 
they  may  occur  occasionally  to  almost  any  child  as  the  result  of  undue 
excitement  and  various  kinds  of  nervous  disturbance.  Somnambulism 
and  somniloquence  are  also  frequent,  and  nocturnal  enuresis  is  exceedingly 
common. 

The  motor  manifestations  of  hysteria  in  children,  in  the  direction 
of  either  spasm  or  paralysis,  are  various  and  frequent.  They  are  char- 
acterised by  an  absence  of  evidence  of  all  recognised  organic  causes ;  but 
their  ultimate  test  is  usually  to  be  found  in  concomitant  manifestations, 
however  slight,  of  mental  disturbance.  "  Fits  "  of  various  kinds  are  very 
common  in  the  subjects  of  these  disorders,  either  with  or  without  apparent 
loss  of  consciousness.  Sometimes  the  whole  attack  consists  of  partial  or 
generalised  spasm,  or  of  tonic  contraction  of  certain  groups  of  muscles, 
without  any  discoverable  affection  of  consciousness.  When  evidence  of 
defect  or  loss  of  consciousness  is  established,  the  diagnosis  of  epilepsy 
cannot  be  easily  rejected ;  and  such  diagnosis  must  always  be  made,  at 
least  provisionally,  in  those  not  infrequent  cases  of  falling  with  giddiness 
and  apparent  temporary  losses  of  consciousness  without  spasm  which  are 
by  no  means  uncommon  in  young  subjects  of  many  kinds  of  hysterical 
display.  The  diagnosis  of  hysteria  as  the  sole  cause  is  easy  only  when 
the  spasms  occur  with  no  loss  of  consciousness  and  are  accompanied  by 
well-recognised  hysterical  phenomena.  Again,  attacks  of  convulsions, 
with  evidence  of  complete  loss  of  consciousness,  often  happen  in  near 
association  in  time  with  typical  hysterical  attacks,  or  alternate  with  them 
at  varying  intervals.  Such  attacks  must  be  regarded  as  true  epilepsy, 
In  a  girl  of  twelve  years  old  I  repeatedly  observed  both  kinds  of  attacks. 
From  the  one,  consisting  of  opisthotonos,  violent  throwing  about  of  the 
limbs,  clenched  fists  and  screaming,  she  could  at  once  be  aroused  by 
a  faradic  current  which  soon  induced  her  to  give  rational  answers  to 
questions ;  while  upon  the  other,  where  the  spasms  were  more  of  the 
regular  epileptic  order  and  there  was  no  screaming,  no  stimulation  what- 
ever had  any  effect.  In  all  the  attacks  of  either  kind  the  eyes  were 
open.  Of  the  typical  liystero-epileptic  attack,  as  rendered  classical  by 
the  description  of  Charcot,  I  have  had  no  experience  in  children ;  and 
it  is  the  rule  that  hysterical  attacks  of  general  convulsions  approaching 
to  this  description  are  seen  only  in  girls  or  boys  nearing  puberty.  I  have 
observed  several  attacks  of  opisthotonic  seizures,  apparent  hallucinations, 


HYSTERIA  AND  FUNCTIONAL  NERVOUS  DISORDER.       3  I  5 

littering  of  various  noises,  screaming,  talking,  rolling  out  of  bed  and 
other  phenomena,  with  certainly  much  indifference  or  complete  "want  of 
response  to  painful  stimuli,  in  hoys  between  twelve  and  fourteen  years 
old. 

The  following  case  of  hysterical  disorder  is  fairly  typical  of  several  that 
I  have  met  with  in  both  sexes  between  the  ages  of  eight  and  fourteen. 
A  girl  of  eleven  began  to  have  frequent  attacks  of  screaming  and  then 
"fainting"  {i.e.  falling  suddenly,  with  apparent  loss  of  consciousness 
sometimes  for  half  an  hour  or  more)  soon  after  being  roughly  handled 
and  much  frightened  by  a  man,  when  she  was  out  in  the  street.  Some- 
times she  would  "bark  like  a  dog,"  and  sometimes  "laugh  idiotically" 
on  coming  to.  For  two  months  before  admission  she  had  spasmodic 
seizures,  kept  her  bed,  and  was  said  to  be  unable  to  stand.  The  attacks 
observed  in  hospital  were  marked  by  opisthotonos,  the  fingers  being 
clenched,  but  the  arms  thrown  wildly  about.  "When  I  first  saw  her  she 
would  neither  speak  nor  act  as  she  was  bid.  Being  placed  on  the  ground 
and  told  to  rise,  she  cried  and  barked  alternately,  and  then  had  a  con- 
vulsion which  lasted  five  minutes.  A  strong  faradic  current  was  applied 
to  her  legs  until  she  gradually  rose  and  danced  about  as  in  extreme  rage. 
Two  days  afterwards  the  child  was  playing  about,  talking  and  walking 
naturally.  She  left  hospital  in  a  fortnight  quite  well,  having  had  no 
relapse  other  than  an  easily  mastered  reluctance  to  walk  by  herself,  after 
she  had  been  up  three  days.  This  girl  had  been  subject  to  infantile 
convulsions,  and  had  an  insane  aunt.  A  very  similar  case  occurred  in 
a  girl  of  seven  with  no  ascertainable  bad  heredity;  but  she  had  had 
measles,  scarlatina,  whooping-cough  and  chicken-pox  at  short  intervals, 
not  long  before  the  nervous  troubles  set  in  with  "pains  all  over  her, 
especially  in  the  legs." 

Localised  spasms  of  groups  of  muscles,  especially  of  a  tonic  character, 
are  not  seldom  met  with.  Besides  those  of  legs  or  arms,  I  have  seen 
a  few  instances  of  rigidity  of  the  muscles  of  the  back  and  neck,  and  one 
of  long-continued  contraction  of  the  muscles  of  one  shoulder,  which  was 
always  kept  elevated  except  in  sleep.  There  were  but  few  other  hysterical 
phenomena  to  mark  the  case ;  but  the  symptoms  ultimately  yielded  to 
neglect  after  making  no  response  to  faradism  or  any  active  treatment. 
In  this  connection  I  "will  but  just  allude  to  frequent  instances  in  children 
of  laryngeal  spasm,  of  the  well-known  short  "hysterical"  cough,  and  of 
attacks  of  rapid  breathing  (sometimes  like  paroxysms  of  asthma),  in  con- 
junction or  alternation  with  various  hysterical  phenomena ;  and  perhaps 
"hysterical  vomiting,"  of  which  I  have  seen  several  well-marked  examples, 
may  be  mentioned  here,  as  possibly  due  to  spasm  of  the  stomach. 

Minor  degrees  of  catalepsy,  consisting  in  a  dazed  condition  with  the 
state  of  "  flexibilitas  cerea"  of  the  limits,  or  in  the  latter  state  alone 


3  1 6  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

without  any  observable  defect  of  consciousness  other  than  lessened  sensi- 
bility of  the  skin,  are,  I  think,  not  uncommon  in  hysterical  and  "  nervous  " 
children.  I  have  several  times  been  able  to  induce  this  condition  readily, 
either  by  merely  placing  the  limbs  in  awkward  positions,  by  previously 
closing  the  e'yes,  or  by  other  simple  "hypnotic"  methods.  It  may 
be  said  incidentally  here  that  some  degree  of  hypnotism  is  readily 
induced  in  many  hysterical  children  of  both  sexes,  as  has  often  been 
shown  in  the  wards  at  Shadwell.  I  would,  however,  as  a  rule  deprecate 
the  frequent  repetition  of  this  practice  in  individual  cases;  except  perhaps, 
in  certain  instances,  with  therapeutic  intent.  Spontaneous  examples  of 
cataleptic  stiffness  of  limbs  may  occasionally  be  observed  in  hysterical 
children  of  any  age.  The  youngest  I  have  seen  was  in  a  girl  of  three, 
who  was  sent  to  me  as  an  instance  of  infantile  paralysis  because  she 
had  never  walked.  I  found  her  surprisingly  emotional,  readily  crying 
and  laughing,  with  the  manner  and  kind  of  self -consciousness  of  a  much 
older  girl ;  and  it  was  observed  before  long  that  she  indulged  in  both 
manual  and  femoral  friction  of  the  vulva.  After  a  few  days  in  hospital 
she  was  induced  to  stand  and  walk  a  little  with  support.  She  often 
remained  sitting  in  one  position  for  long ;  and  I  soon  ascertained  that  her 
limbs  could  be  placed  and  retained  for  a  considerable  time  in  the  most 
uncomfortable  attitudes.  For  more  than  a  quarter  of  an  hour  on  several 
occasions  she  sat  with  her  thighs  elevated  at  an  angle  of  45°  to  the 
seat  of  the  chair,  her  legs  extended,  and  her  arms  held  vertically ; 
occasionally  whimpering  a  little,  but  making  no  effort  to  change  the 
position  in  which  her  limbs  had  been  placed.  This  condition  gradually 
disappeared,  but  during  the  whole  of  her  stay  in  the  hospital  she  was 
highly  emotional. 

Other  disorders  of  movement,  occurring  in  the  hysterical,  are  rhyth- 
mical tremors  supervening  on  falls  or  other  kinds  of  shock.  Such  cases, 
however,  are  not  confined  to  the  hysterical ;  and  some  have  seemed  to  me 
to  be  referable  to  the  category  of  organic  mischief.  In  two  cases  of  this 
kind,  aged  eight  and  nine  respectively, — one  with  the  "  deep  reflexes  "  in 
all  extremities  much  increased,  the  other  normal  in  this  respect,  nystag- 
mus being  absent  in  both, — a  few  weeks'  rest  in  bed  was  followed  by 
complete  recovery.  In  a  few  others,  beginning  in  later  childhood  and 
making  no  improvement,  although  accompanied  by  hysterical  symptoms 
and  showing  no  evidence  of  structural  change  anywhere,  there  seemed 
grave  reason  to  fear  organic  disease  such  as  disseminated  sclerosis.  I 
may  here  remark  that,  in  children  as  well  as  in  adults,  whatever  their 
symptoms,  we  should  never  omit  to  search  as  carefully  for  organic 
disease  when  hysterical  phenomena  are  prominent  as  in  those  where 
they  are  absent.  Organic  disease  and  many  structural  lesions  concur 
with  hysterical  display,  and  are  often  among  its  exciting  causes. 


HYSTERIA  AND  FUNCTIONAL  NERVOUS  DISORDER.       3  I  7 

Repeated  and  larger  movements,  such  as  head-nodding  and  head-rotation, 
bowing  of  the  body  &c,  already  mentioned  under  the  heading  of  "local 
spasms,"  occur  in  the  hysterical,  and  sometimes  are  equally  evanescent 
with  the  other  symptoms ;  but  such  movements,  again,  are  by  no  means 
always  of  hysterical  nature.  In  this  connexion  I  would  mention  one 
case  I  have  seen,  in  a  little  child,  of  frequent  attacks  of  rotation  while  in 
the  sitting  position  on  the  bed  or  floor ;  the  child  seeming  dazed  at  the 
time  and  afterwards  exhausted.  In  close  alliance  with  this  are  the  cases 
described  by  many  writers  as  "  chorea  magna,"  a  combination  of  attacks 
of  running,  jumping,  and  various  co-ordinated  movements  with  all  kinds 
of  psychical  and  sensory  affections.  Many  striking  instances  of  this  are 
detailed  by  Professor  Henoch. 

Of  impairment  or  loss  of  motor  power  hysteria  supplies  many  instances. 
Simple  ataxia  of  the  limbs  is  not  common  in  my  experience ;  but  I  have 
seen  some  cases  in  young  and  older  children,  in  association  with  obvious 
psychical  hysteria,  where  there  seemed  to  be  no  evidence  of  further 
disease.  Some  became  rapidly  well  with  ordinary  routine  treatment,  such 
as  hospital  life  affords ;  while  in  others,  which  persisted,  both  diagnosis 
and  prognosis  appeared  obscure. 

Motor  paralysis  of  whole  limbs,  as  often  seen  in  hysterical  adults,  is 
not  prominent  among  my  cases  and  is  rare  in  young  children.     I  have 
seen  a  few  instances  of  temporary  paralysis  of  an  arm  or  leg  in  children 
under  five  years  old,  which  from  the  whole  circumstances  of  the  case 
appeared  to  be  clearly  hysterical ;  and  a  case  of  eighteen  months  old, 
reported  by  Gillette,  is  quoted  by  Dr.  C.  K.  Mills  in  his  above-mentioned 
article.     Much  more  common  are  local  paralyses  of  the  eye-muscles,  such 
as  ptosis ;  and  ap>lionia,  caused  by  paralysis  of  the  vocal  cords.     I  have 
seen  a  number  of  cases  of  the  latter  affection  in  boys  and  girls  between 
seven  and  fourteen  years  old,  some  of  them  supervening  on  chest-colds  or 
definite  laryngeal  catarrh ;  while  others  were  not  referable  to  any  previous 
local  disorder.     Hysterical  aphonia  in  children  is  often  eminently  curable 
by  the  infliction  of  pain  which  causes  crying.     I  have  thus  cured  many 
cases  of  long  standing  by  the  use  of  a  strong  faradic  current,  one  or  both 
electrodes  being  always  placed  on  the  front  of  the  neck  in  the  case  of 
children  old  enough  to  appreciate  this  direction  of  local  treatment.     I 
am  well  convinced,  from  numerous  and  various  trials,  that  the  cures  of 
hysterical  aphonia  which  are  reported  from  time  to  time  as  the  result  of 
"  laryngeal  faradisation,"  whether  external  or  internal,  are   entirely  of 
psychical  nature,  and  in  no  way  referable  to  any  direct  effect  on  the 
faultily  acting  cords.     It  is  always  well  to  induce  the  child  to  count  or 
repeat  sentences  as  a  condition  of  the  cessation  of  the  painful  application. 
When  aphonia  is  the  chief  or  last  lingering  symptom  of  hysterical  dis- 
order, a  single  use  of  the  battery  is  often  enough  to  abolish  the  affection 


3  I  8  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

permanently.  In  many  cases,  however,  the  aphonia  returns,  or  is  replaced 
by  some  other  hysterical  phenomenon.  It  may  be  taken  as  certain  that, 
as  long  as  functional  aphonia  is  treated  locally  and  chronically,  there 
will  be  no  improvement.  The  cases  which  yield  to  the  treatment  above 
mentioned  yield  at  once ;  those  which  do  not  must  be  treated  not  locally, 
but  by  change  of  surroundings  and  other  general  measures.  One  case, 
which  was  quickly  cured  by  faradism,  was  in  a  boy  of  eleven  who  had  been 
subject  to  epileptic  convulsions  and  to  frequent  pains  in  the  head  until 
he  was  six  years  old.  Four  months  before  admission  fits  of  apparent  un- 
consciousness recurred  without  convulsions,  and  he  became  completely 
aphonic.  On  admission  he  looked  miserable  and  only  whispered ;  but 
after  one  application  of  faradism  all  his  symptoms  disappeared,  and  he 
left  in  three  weeks  quite  well  and  lively.  He  had  four  elder  sisters,  all 
subject  to  hysterical  attacks. 

Hysterical  failure  of  the  peroneal  muscles  on  one  or  both  sides,  causing 
talipes  with  or  without  contraction,  is  very  common  in  hysterical  children 
between  ten  and  fourteen  ;  and  sometimes  we  meet  with  other  forms  of  de- 
formity from  a  similar  cause.  Such  symptoms  are  apt  to  begin  suddenly  ; 
some  however,  as  in  aphonia,  supervening  on  pain  or  traumatism.  I  have 
seen  one  or  two  typical  cases  growing  directly  out  of  true  rheumatism ; 
but  pain  and  tenderness  over  the  feet  and  ankles,  apparently  of  purely 
hysterical  kind,  without  any  trace  or  suspicion  of  further  disease,  is  a 
fairly  common  antecedent.  In  some  instances  the  feet  preserve  the 
normal  position  when  the  patient  is  lying  down  unobserved.  These 
cases  are  often  perpetuated  by  orthopoedic  instruments  and  operations, 
of  which  I  have  seen  some  disastrous  examples,  as  well  as  of  others  whose 
disability  was  indefinitely  prolonged  by  confinement  to  bed  owing  to 
mistaken  diagnosis.  A  striking  case  is  that  of  a  highly  emotional 
and  precocious  girl  of  twelve  years  old  who  suffered  from  double 
functional  talipes  varus  of  long  standing,  accompanied  by  great  ten- 
derness of  the  feet  and  alleged  inability  to  stand.  The  diagnosis  of 
chronic  rheumatic  arthritis  had  been  made,  apparently  from  the  pre- 
existence  of  some  slight  swelling ;  and  the  prognosis  of  a  life  in  bed  had 
been  pronounced  and  accepted.  "With  a  little  firm  "  moral "  treatment 
out  of  bed  and  systematic  neglect  the  child  rapidly  improved,  and  after 
a  few  weeks  was  running  and  riding  about. 

Prolonged  and  marked  hysterical  paralysis,  as  I  have  said,  is  not 
frequent;  is,  I  think,  seen  only  in  children  approaching  the  age  of 
puberty ;  and,  is  perhaps  always  accompanied  by  other  marked  signs  of 
the  hysterical  neurosis.  A  girl  of  thirteen  was  admitted  into  hospital 
about  a  month  after  she  had  lost  the  use,  first  of  the  right  leg,  and  then 
of  the  left,  soon  after  a  fit  which  was,  judging  from  the  history,  almost 
certainly  epileptic.     She  had  had  several  convulsive  fits  up  to  two  years 


HYSTERIA  AND  FUNCTIONAL  NERVOUS  DISORDER.       3  I  9 

old ;  but  had  since  then  been  healthy  and  of  good  intelligence,  though 
very  excitable.  There  was  a  history  of  much  consumption  in  the  family 
of  her  father,  who  had  suffered  from  several  fits  during  infancy  and 
childhood.  8 he  was  apparently  unable  to  move  her  lower  extremities 
at  all ;  passed  urine  and  faeces  under  her ;  and  had  much  though  not 
universally  diminished  sensibility  to  touch,  heat,  pricking  and  faradism. 
She  was  plump,  with  a  somewhat  silly  neurotic  expression  ;  and  behaved 
generally  like  a  much  younger  child.  When  her  legs  were  lifted  up  as 
she  lay,  and  let  go,  they  dropped  heavily  and  were  apparently  toneless ; 
but  they  were  drawn  up  slightly,  and  never  dragged,  when  she  was  re- 
moved from  bed  and  held  up  by  the  armpits.  Insensibility  to  all  forms  of 
cutaneous  stimulation  over  the  whole  of  the  lower  extremities  appeared 
almost  absolute.  The  knee-jerks  were  normal,  there  was  no  ankle- 
clonus,  and  all  reactions  to  both  kinds  of  current  were  everywhere 
natural.  After  ten  days,  with  encouragement  and  repeated  faradism, 
she  was  able  to  stand  a  little  with  support ;  but  this  improvement  soon 
declined.  The  cutaneous  anaesthesia  so  increased  in  extent  and  character 
that  she  became  seemingly  insensible  to  almost  everything,  the  strongest 
faradism  being  only  felt  on  the  face  and  ears.  She  was  then  isolated, 
attended  for  a  while  almost  wholly  by  nurses,  and  treated  by  occasional 
cold  douches  and  once  or  twice  by  the  actual  cautery  to  her  legs ;  but  as 
a  rule  was  observantly  neglected.  After  a  month  I  found  that  she  could 
walk  with  but  little  support ;  and  very  soon,  on  being  promised  return 
to  the  general  ward  when  she  could  walk  alone,  she  got  about  by  herself 
and  was  quite  cleanly.  At  this  period  the.  temperature  rose  several 
times  to  between  101°  and  1040  F.,  with  extreme  flushing  of  the  face; 
and  three  weeks  after  the  improvement  had  been  noticed  she  had  two 
severe  epileptic  fits  in  one  day,  with  intense  flushing  of  the  whole 
surface  of  the  body.  She  continued  to  improve  otherwise ;  but  after 
another  fortnight  had  twelve  more  fits  near  together  which  had  all  the 
signs  of  epilepsy.  Tor  a  month  subsequently,  until  discharge,  she  seemed 
perfectly  well  in  mind  and  body,  occasionally  however  passing  water 
involuntarily.  This  case  in  several  points  differed  from  one  of  pure 
hysteria,  mainly  hysterical  though  it  clearly  was. 

Among  sensory  disturbances  anaesthesia  and  analgesia  of  varying 
distribution  are,  in  my  experience,  by  no  means  rare  in  children,  either  as 
the  leading  symptoms  or  as  subordinate  to  other  hysterical  phenomena, 
I  have  alluded  to  this  under  the  head  of  chorea,  and  have  seen  several 
cases  in  little  children  comparable  to  an  interesting  series  published  by 
Dr.  T.  Barlow  in  the  British  Medical  Journal  of  December  5,  1881. 
The  following  case  which  I  reported  at  length  in  Brain,  Part  XXIV., 
is  striking  enough  for  short  quotation. 

A  boy  of  thirteen,  with  an  epileptic  father,  and  a  history  of  headaches, 


320  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

occasional  falling  with  "faintness,"  and  a  "fit"  in  the  night  shortly 
before  admission,  came  into  hospital  complaining  of  pain  and  tenderness 
over  the  outer  surface  of  the  right  thigh,  of  complete  anaesthesia  in  his 
right  thumb,  and  of  sometimes  "  seeing  everything  red."  There  was 
no  evidence  over  the  whole  of  the  right  thumb  of  feeling  either  touch, 
pricking,  burning  or  faradism ;  and  a  needle  was  several  times  thrust 
suddenly  and  deeply  under  the  nail  when  he  was  off  his  guard  or  care- 
fully blindfolded.  The  boy  could  walk  well,  and  stood  steady  with  his 
eyes  shut.  Some  weeks  later  he  complained  of  pain  in  his  legs.  It 
was  then  found  that  there  was  no  response  to  any  of  the  above-men- 
tioned stimuli  applied  to  his  lower  extremities  up  to  an  inch  and  a  half 
above  the  upper  border  of  the  patella?.  Blisters  and  strong  faradism 
and  other  severe  applications  to  the  affected  parts  were  repeatedly  and 
ineffectively  tried.  After  about  five  months,  during  part  of  which  time 
he  had  been  at  home  in  the  same  condition,  he  was,  at  my  request, 
admitted  into  the  London  Hospital  under  Dr.  Hughlings  Jackson,  where 
after  strong  faradism,  all  his  symptoms  disappeared  in  a  few  days. 
While  he  was  at  Shadwell  there  was'  no  psychical  aberration  observable 
in  the  boy,  who  was  reported  to  be  fond  both  of  his  school  and  his  home. 
If  this  case  be  regarded,  as  it  was  by  some,  as  malingering,  I  would 
submit  that  even  the  absence  of  discoverable  motive  is  far  less  remark- 
able than  the  complete  control  shown  over  the  expression  of  what  must 
have  been  severe  suffering.  It  is  scarcely  possible  but  that  this  striking 
case  of  anaesthesia  was  perfectly  genuine. 

Complete  hemi-anaesthesia  with  hemiplegia  I  have  not  yet  seen  below 
the  age  of  puberty.  Dr.  Goodhart,  however,  quotes  two  cases  in  boys  of 
eleven  and  twelve,  giving  the  details  of  one  which  appeared  to  be  typically 
hysterical  in  its  character  and  history.  Neither  have  affections  of  the 
senses  of  sight,  hearing  or  smell  been  at  all  frequent  in  my  experience, 
although  I  have  seen  some  examples  of  apparently  unilateral  amaurosis 
and  loss  of  smell,  and  more  of  seeming  impairment  of  taste.  The 
investigation,  however,  of  alleged  anaesthesia,  and  notably  of  the  special 
senses,  is  very  difficult  in  children,  with  the  exception  of  those  cases 
where  complete  analgesia  can  almost  certainly  be  established  by  severe 
tests. 

Cutaneous  hyper cestliesia  and  complaints  of  great  pain  in  joints,  limbs, 
abdomen,  head  and  many  other  parts  are  of  very  frequent  occurrence 
in  children,  and  are  sometimes,  though  not  often,  distinguished  with 
difficulty  from  the  results  of  organic  disease.  Numerous  examples  might 
be  given  of  the  hysterical  joint  so  familiar  in  patients  beyond  the  age 
of  puberty.  Sometimes  there  is  slight,  and  occasionally  considerable, 
swelling ;  but,  as  a  rule,  this  affection  can  be  established  as  functional  by 
the  absence  of  objective  evidence  of  arthritis,  by  free  movement  under 


HYSTERIA  AND  FUNCTIONAL  NERVOUS  DISORDER.       32  I 

force  or  chloroform,  and  by  some  of  the  usual  psychical  accompaniments 
of  hysteria.  More  obscure,  for  a  time  at  least,  are  cases  marked  by 
complaint  of  severe  pain  and  tenderness  over  the  abdomen,  which,  with 
rigidity  of  the  abdominal  walls  and  sometimes  much  abdominal  dis- 
tension, closely  simulate  peritonitis.  Such  cases  are  also  apt  to  be 
marked  by  some  pyrexia ;  and  I  may  here  observe  that  I  have  many 
times  established  the  fact  of  an  association  between  severe  abdominal 
pain  and  at  least  temporary  rises  of  temperature  at  all  ages,  especially  in 
childhood  and  youth,  with  or  without  suspicion  of  hysteria.  Among 
many  and  various  cases  of  hysterical  pain  and  tenderness  I  may  mention 
an  instance  of  a  boy  of  eight,  who  had  lain  in  bed  for  five  months  with 
the  complaint  of  acute  abdominal  tenderness,  and  was  completely  cured 
by  one  application  of  strong  faradism ;  and  another  of  a  girl  of  eleven, 
with  similar  suffering  and  frequent  attacks  of  paraplegia  off  and  on  for 
four  years,  who  recovered  after  three  faradisations,  and  remained  well  to 
my  knowledge  for  three  years. 

Of  nervous  pyrexia  I  have  spoken  in  the  section  concerning  fevers. 
I  will  here  but  refer  to  one  remarkable  case  out  of  others  that  were 
perhaps  more  certainly  of  hysterical  origin,  selecting  this  on  account  of 
its  peculiarity.  This  case  was  under  my  observation  for  two  months, 
and  closely  simulated  tertian  ague.  There  was,  however,  absolutely  no 
other  evidence  of  this  disease,  and  both  quinine  and  arsenic  were  wholly 
ineffectual.  In  spite  too  of  antipyrin  and  other  measures  taken  to 
reduce  temperature  the  attacks  of  pyrexia  continued,  but  at  last  gradually 
disappeared.  In  the  intervals  of  these  attacks  the  child  seemed  usually 
very  well ;  but  she  had  marked  psychical  evidence  of  hysteria  and  often 
had  fits  of  screaming  and  apparently  causeless  vomiting  in  the  apyretic 
intervals.  There  was  no  abnormality  of  the  discs,  nor  any  other  evidence 
whatever  of  organic  disease. 

To  conclude  this  sketch  of  the  symptomatology  of  hysteria  I  would 
mention  but  two  more  cases.  One  was  that  of  a  girl  under  my  obser- 
vation at  intervals  for  some  years  between  the  ages  of  ten  and  fourteen. 
She  had  at  first  chorea,  most  marked  in  the  left  arm,  rigidity  of  the  left 
leg,  and  complete  anaesthesia  of  the  right  forearm  with  rhythmical  move- 
ments like  those  of  disseminated  sclerosis.  There  were  frequent  re- 
currences of  these  and  other  symptoms  in  various  combinations,  and 
throughout  she  showed  a  markedly  hysterical  character.  Her  last  ad- 
mission was  for  a  first  attack  of  acute  rheumatism  some  months  after  the 
subsidence  of  her  hysterical  symptoms.  She  had  danced  several  times 
in  public  before  she  was  ten  years  old.  The  next  case  illustrates  the 
trance-like  conditions  often  seen  at  or  after  the  age  of  puberty,  but  very 
rarely,  I  think,  at  an  earlier  age ;  as  well  as  those  equally  rare  disturb- 
ances of  nutrition  with  which  we  are  familiar  in  older  patients  under 

X 


322  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

the  name  of  "anorexia  nervosa"  or  "apepsia  hysterica" — a  class  of  cases 
which  often  yield  to  the  fashionable  and  expensive  massage  treatment, 
but,  much  more  often  than  is  generally  believed,  relapse  thereafter,  or  fail 
in  some  other  but  equally  or  more  deplorable  direction.  A  girl  of  eleven, 
with  deeply  neurotic  parents,  herself  the  idolised  centre  of  the  family, 
had  suffered  for  many  months  from  headache  of  the  nature  of  clavus, 
with  intervals  of  complete  apathy  ;  lying  with  wide  open  and  un-winking 
eyes  for  several  days  together.  Occasionally  she  had  attacks  of  general 
convulsions,  but  could  then  always  be  roused  by  vigorous  measures.  She 
wasted  rapidly,  and,  although  she  made  attempts  to  eat,  was  apparently  un- 
able to  take  more  than  an  occasional  biscuit,  vomiting  up  nearly  everything 
else  she  attempted.  She  had  had  "  massage  "  at  home  by  a  trained  nurse 
for  many  weeks,  but  all  trials  of  forced  feeding  were  failures.  Kemoved 
from  home  in  an  extreme  stage  of  emaciation,  and  isolated  for  a  short 
time  with  no  active  treatment,  she  improved  slightly  in  flesh,  and  solid 
food  placed  and  left  by  her  was  eaten  and  not  vomited.  Her  parents 
insisted  on  her  return  after  less  than  a  fortnight,  and  I  was  informed 
several  weeks  afterwards  that  she  was  being  "  massaged "  and  was  still 
"  almost  in  a  dying  condition." 

Of  the  diagnosis,  prognosis  and  treatment  of  hysterical  affections  in 
children  much  has  been  said  incidentally  in  the  foregoing  remarks.  The 
differential  diagnosis  of  the  numerous  hysterical  affections  which  more  or 
less  closely  simulate  organic  disease  can  only  be  made  by  means  of  care- 
ful observation  and  reflection,  and  a  sound  knowledge  of  the  signs  and 
symptoms  of  such  disease  and  of  the  various  methods  of  investigation. 
The  previous  and  family  history  of  the  case  and  the  psychical  condition 
are  most  important  factors  in  diagnosis  when  the  most  salient  symptoms 
complained  of  are  physical,  such  as  convulsions,  or  paralysis,  or  are  pro- 
minently those  of  pain  or  loss  of  feeling.  At  the  same  time  I  must 
repeat  that  in  children,  as  well  as  in  adults,  both  slight  and  serious  organic 
diseases  are  often  apt  to  excite  and  to  be  concealed  by  phenomena  of 
clearly  hysterical  nature. 

Generally  speaking  the  prognosis  of  hysterical  affections  in  children 
below  puberty  is  good,  provided  that  the  treatment  be  judicious.  It  is 
more  or  less  grave  as  a  rule,  especially  as  regards  recurrence  in  one  or 
other  form,  when  there  is  a  bad  family  history  of  neurotic  disorder.  In 
the  well-to-do  classes  the  ultimate  forecast  is  perhaps  on  the  whole  rather 
worse  than  among  the  poor;  for  in  many  cases  in  the  latter  category 
external  excitants,  such  as  fright  and  pain  and  traumatism,  are  more 
numerous,  and  often  play  a  larger  proportionate  part  than  the  constitu- 
tional neurosis  in  the  production  of  hysterical  disorder.  In  other  words, 
though  great  stresses  may  require  a  less  deeply  neurotic  constitution  for 
the  production  of  hysterical  phenomena,  the  disorder  will  so  much  the 


HYSTERIA  AND  FUNCTIONAL  NERVOUS  DISORDER.       323. 

more  readily  disappear  on  the  removal  of  those  stresses  and  the  supply 
of  fresh  surroundings.     On  the  other  hand,  a  deeply  neurotic  constitution 
may  almost  spontaneously  or,  at  least,  with  the  slightest  excuse  breed 
hysterical  display ;  and  the  ultimate  cure  of  such  cases,  often  met  with 
among  the  Avell-to-do,  is  difficult  or  doubtful.      However  this  may  be,  this 
much  is  certain,  that,  taking  all  kinds  of  hospital  cases  together  and  com- 
paring them,  in  point  of  response  to  treatment,  with  those  occurring  in 
the  well-to-do  and,  especially,  the  wealthy  classes,  the  former  group  have 
a  decided  advantage  over  the  latter.     Much  of  this  difference  is  of  course 
to  be  accounted  for  by  the  great  aptness  of  hospital  treatment  to  most 
cases  of  hysteria ;  for  in  the  general  ward  of  a  hospital  the  child  is  in  a 
much  less  self-important  position  than  it  can  be   even  in  any   private 
institution,  although  quite  separated  from  its  own  home  and  relatives. 
In  a  hospital,  again,  more  than  anywhere  else  can  the  system  of  observant 
neglect,  so  essential  to  the  cure  of  many  cases,  be  efficiently  carried  out. 
It  is  of  course  all-important  in  the  treatment  of  hysterical  children  to 
minimise  or  remove  all  conditions,  both  physical  and  psychical,  Avhich 
tend  to  emphasise  their  neurosis  or  to  occasion  its  display.     All  matters 
of  hygiene  and  nutrition  should  be  carefully  attended  to,  anaemia  or  any 
other  coincident    malady    energetically   combated,   and  an  outdoor  life 
insisted  on  as  much  as  possible.     The  patients  must  always  be  removed 
from  the  care  of  nervous  or  hysterical  relatives ;  and  bad  cases,  as  a  rule, 
are  better  treated  away  from  home.     But  few  subjects  of  marked  hysteria 
are  of  physically  robust  constitution,  unless  the  exciting  causes  of  the 
display  are  very  plain  ;  and  such  drugs  as  cod-liver  oil,  arsenic  and  iron  are 
often  of  the  highest  value.     I  have  already  indicated  the  cases  in  which 
local  treatment  of  affected  parts  may  be  of  use.     In  many  instances,  how- 
ever, local  treatment  of  any  kind  perpetuates  the  mischief.     Each  case 
must  be  treated  on  its  own  merits,  and  more  or  less  success  will  generally 
be  the  reward  of  good  judgment  and  management.     The  child's  attention 
must  be  directed  to  external  things,  and  active  sympathy  must  be  with- 
held; but,  all  the  same,  systematically  harsh  treatment,  and  even  the  least 
degree  of  the  vindictive  attitude,  should  be  carefully  avoided.     It  is  the 
great  difficulty  of  steering  a  course  between  the  petting  and  scolding  of 
hysterical  children  that  renders  most  mothers  and  relatives  the  worst 
attendants  possible.     But  very  few  among  even  intelligent  people  can 
appreciate  the  nature  of  hysteria ;  and  those  who  are  once  convinced,  as 
some  may  be,  that  the  hysterical  child  is  not  the  subject  of  what  they 
understand  as  serious  disease,  conclude  as  a  rule  that  the  case  is  one  of 
shamming  and  viciousness,  and  treat  it  according  to  the  dictates  of  their 
own  ethical  or  religious  creed. 

Being  of  opinion  that  hysteria  in  the  young  is  far  more  often  either 
overlooked,  mistaken  or  disastrously  mismanaged  and  maltreated  at  both 


324  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

lay  and  professional  hands  than  in  adults,  and  desiring  to  give  prominence 
to  what  is  called  the  moral  method  of  cure,  I  shall  say  nothing  here 
of  the  minor  details  of  drug  or  other  treatment  which  individual  cases 
very  often  necessitate.  I  would  only  warn  the  reader  to  avoid  as  much 
as  possible  the  use  of  any  sedative  or  narcotic  medicines,  including  the 
bromides ;  and  rarely,  if  ever,  to  continue  them. 

From  certain  experiments  in  hypnotism  with  "  suggestion,"  conducted 
hy  Dr.  E.  E.  Ware,  the  resident  medical  officer  at  Shadwell  Hospital, 
I  am  somewhat  inclined  to  believe  that  benefit  may  result  in  some  cases 
in  childhood  from  the  use  of  this  method.  In  two  instances  children 
who  had  long  and  daily  suffered  from  excessively  frequent  fits,  of  a  nature 
difficult  to  distinguish  from  epilepsy,  remained  well  for  several  weeks 
after  a  few  applications  of  hypnotism,  during  which  they  had  been  told 
that  their  seizures  would  not  recur  in  the  future.  In  one  case  there 
were  no  fits  for  several  months ;  after  which  time,  however,  the  patient 
made  no  further  appearances  at  the  hospital. 


OHAPTEE    VII. 

HEADACHE. 

As  in  adults,  so  in  children,  headache  is  a  symptom  of  various  morbid 
conditions ;  but  it  is  not  until  after  the  age  of  five  or  six  years  that 
it  becomes  recognisably  prominent  as  the  mark  of  a  more  or  less  inde- 
pendent neurosis.  Before  the  speaking  age  headache  may  be  evidenced 
by  facial  expression,  with  knitting  of  the  brows  ;  and  by  great  irrita- 
bility, restlessness  and  frequent  rolling  of  the  head.  In  quite  young 
children  we  must  think  of  ear-disease  ;  meningitis,  especially  tubercular  ; 
brain  tumours  and  abscess ;  syphilis ;  and  the  onset  of  any  of  the  acute 
febrile  diseases,  especially  pneumonia  and  enteric  fever :  making  our 
clinical  search  accordingly  for  concomitant  symptoms  of  these  several 
affections.  In  older  children,  besides  these  causes,  faulty  ocular  accommo- 
dation, and  notably  hypermetropia,  must  always  be  remembered  as  a  fre- 
quent source  of  headache  which  is  mainly  frontal  in  site,  sometimes  accom- 
panied by  squinting,  and  usually  remittent  or  altogether  absent  when 
the  eyes  are  not  used  for  reading  or  with  other  fixed  purpose.  Ansemia 
alone,  from  whatever  cause  arising,  is  frequently  associated  with  headache, 
especially  in  cases  beyond  early  childhood,  and  is  often  apparently  causal ; 
but  I  have  over  and  over  again  failed  to  find  any  evidence  of  pain  in  the 
numerous  cases  I  have  seen  of  profound  ansemia  in  young  children  in 


HEADACHE.  325 

connexion  with  splenic  enlargement.  Rheumatism  is  frequently  accom- 
panied hy  headache,  and  we  should  look  for  evidence  of  this  affection  in 
cases  not  otherwise  explicable ;  bearing  in  mind  that  it  is  often  incon- 
spicuous in  childhood,  especially  as  to  its  arthritic  manifestations,  and  that 
its  diagnosis  is  not  seldom  aided  by  the  discovery  of  a  rheumatic  family 
history.  Syphilis  should  always  be  remembered  as  a  possible  cause  of 
headache  in  children  at  any  age ;  and  such  headache  is  not  necessarily 
accompanied  by  more  definite  symptoms  of  syphilis.  Violent  or  repeated 
coughing  is  a  common  cause  of  headache  both  in  children  and  adults ; 
and  in  some  cases  of  chronic  cough,  which  are  neglected  or  regarded 
as  incurable,  the  symptom  of  headache  alone  may  be  complained  of  and 
unsuccessfully  treated  in  ignorance  of  its  real  causation.  Hysterical 
headache,  of  which  I  have  seen  several  examples  both  in  boys  and  girls, 
can  often  be  clearly  discovered  by  concomitant  symptoms  and  the  success 
of  appropriate  treatment ;  but  purely  neuralgic  headache,  of  the  type  so 
common  in  adults,  is,  like  other  neuralgiae,  of  uncommon  occurrence  before 
puberty.  Gastric  disturbance,  in  popular,  and,  sometimes,  in  medical 
parlance,  covers  a  multitude  of  headaches ;  but,  apart  from  acute  attacks 
of  gastric  catarrh,  which  are  as  a  rule  demonstrably  dependent  on  in- 
jurious ingesta  and  accompanied  by  vomiting,  the  stomach  in  my  opinion 
is  but  rarely  accused  with  justice  of  causing  prominent  and  recurrent 
headaches  in  childhood.  I  am  convinced  by  long  experience  that  in 
children,  no  less  than  in  adults,  an  immense  number  of  cases  of  head- 
ache, although  often  apparently  induced  by  dietetic  causes  or  associated 
with  vomiting,  and  then  commonly  called  "  bilious  attacks,"  are  due  to 
the  underlying  and  practically  primary  neurosis  presently  to  be  referred 
to  under  the  name  of  "  migraine."  In  some  cases,  however,  headache  is 
undoubtedly  part  of  the  symptoms  due  to  what  is  known  as  lithasinia. 
Of  the  headaches  which  accompany  valvular  heart-disease,  renal  disorder, 
fevers,  and  many  other  maladies,  presenting  nothing  peculiar  to  child- 
hood, I  need  not  speak.  The  foregoing  sketch  of  the  clinical  conditions 
of  headache  refers  only  to  this  affection  as  an  apparently  isolated  or,  at 
least,  pre-eminent  complaint. 

Migraine,  by  which  we  are  to  understand  a  neurosis,  expressed  by 
paroxysms  of  headache  and  disturbed  vision,  accompanied  often  by 
vomiting,  and  tending  to  recur  through  a  great  part  of  life,  is  a  very 
frequent  disorder  of  childhood,  making  its  first  appearance  in  most  cases 
before  the  age  of  ten  years,  and,  not  seldom,  much  earlier.  Like  other 
neuroses,  such  as  hysteria  and  epilepsy,  it  may  be  latent,  and  thus 
roused  into  expression  by  strong  stimuli  alone.  This  is  evidenced  by  its 
occurrence,  in  some  few  persons,  only  after  prolonged  fatigue,  mental 
excitement,  or  the  nervous  depression  caused  by  severe  illness ;  but  we 
rarely  meet  with  those  who  can  number  only  one  or  two  attacks.     My 


326  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

own  experience  is  in  accord  with  the  well-known  dictum  that  migraine 
is  often  allied  with  a  tendency  to  gout. 

For  full  description  of  the  clinical  symptoms  of  migraine,  and  dis- 
cussion of  its  pathogeny,  I  must  refer  to  larger  and  systematic  works ; 
and  would  only  state  here  that  my  experience  of  what  I  regard  as 
this  affection  in  childhood  justifies  the  now  prevalent  conception  of 
migraine  as  a  primary  neurosis,  and  therefore  as  not  ultimately  attribut- 
able  to  erroneous  dieting  or  to  faulty  processes  in  the  stomach,  liver  or 
other  organs.  The  hypothesis  of  "  litheernia  "  as  the  cause  of  this  malady, 
scantily  supported  by  facts  at  the  best,  and  failing  to  cover  either  the 
symptoms  or  the  clinical  concomitants  of  migraine,  is,  in  my  opinion,  in 
no  way  supported  by  the  study  of  the  disorder  as  it  undoubtedly  occurs 
in  childhood. 

In  the  earliest  cases  attacks  of  vomiting  are  very  prominent,  although 
always  preceded  by  either  the  evidence  or  the  definite  complaint  of 
headache ;  while  the  existence  of  the  subjective  ocular  symptoms,  but 
rarely  quite  absent  in  the  adult,  can  of  course  be  far  less  often  established 
in  childhood.  The  popular  term  "  sick-headache,"  which  is  often 
applied  to  this  affection,  is  especially  appropriate  to  its  manifestations  in 
childhood ;  and  in  many  cases  we  find  that,  as  years  go  on,  the  sickness 
diminishes  or  disappears,  leaving  only  the  headache  with  or  without 
the  visual  disturbance.  In  many  of  the  past  and  current  writings  on 
migraine  in  childhood  the  symptomatic  description  is  taken  from  the 
typical  accounts  of  the  disease  as  best  known  in  adults,  instead  of  being 
based  on  direct  clinical  study  from  young  subjects ;  and  therefore  its 
frequent  confusion  with  gastric  disorder  or  "  bilious  attacks  "  is  ignored 
or  slighted.  In  a  modern  article  on  this  matter  I  find,  as  an  example  of 
this  error,  the  statement  that  the  chief  difficulties  in  diagnosis  are  caused 
by  organic  cerebral  disease  and  petit-mal.  Now  the  prominent  vomiting 
in  the  migraine  of  childhood,  and  the  not  infrequent  sequence  of  the 
attack  on  either  a  surfeit  or  an  impropriety  of  diet,  cause  a  vast  number 
of  cases  to  be  attributed  to  diet  or  disorder  of  stomach  or  liver;  and 
lead  to  much  laboriously  unsuccessful  treatment  by  strict  dieting  with 
lessening  of  nitrogenous  food,  by  purges,  mercurial  and  otherwise,  and 
by  chemical  remedies  directed  to  modify  the  gastric  secretions.  The 
avoidance  of  certain  articles  of  diet,  which  seem,  in  some  few  cases, 
to  determine  an  attack,  is  clearly  therapeutic  up  to  a  certain  point ;  but 
my  experience  has  amply  taught  me  that  not  only  do  numerous  cases 
of  paroxysmal  migraine  occur  when  the  child  has  been  uniformly  well 
dieted  and  has  had  good  health  in  the  intervals,  but  also  that,  in  almost 
every  case  I  have  inquired  into  where  the  attacks  have  been  attributed 
by  the  parents  to  indigestion  or  biliousness,  there  was  an  acknowledged 
absence  of  any  such  exciting  cause  in  many  or  most  of  the  paroxysms. 


HEADACHE.  327 

In  proportion,  indeed,  to  the  intelligence  of  the  parents  I  have  usually 
found  that  their  diagnosis  of  "  biliousness "  is  admitted  by  them  to  be 
merely  an  inference  from  the  fact  of  sickness,  and  not  from  the  observa- 
tion of  any  dietetic  cause,  at  the  absence  of  which  they  very  frequently 
express  their  wonder.  I  can  further  say  that,  in  the  immense  majority 
of  recurrent  sick-headaches  which  I  have  treated  in  children  who  were 
the  alleged  subjects  of  bilious  attacks  and  who  had  been  strictly  dieted 
under  medical  orders,  I  have  never  seen  increase,  but  usually  decrease,  of 
the  symptoms  after  the  discontinuance  of  all  strict  dieting  and  of  drugs 
directed  to  disorder  of  the  alimentary  system.  In  the  sick- headaches  of 
children,  as  in  those  of  adults,  we  find  an  hereditary  history  of  migraine 
and  other  definite  neuroses,  such  as  neuralgia,  epilepsy,  hysteria  and 
insanity,  in  many  cases ;  in  children,  indeed,  according  to  my  experience 
such  a  history  obtains  in  a  considerable  majority.  Further,  whether 
there  be  such  an  hereditary  neurotic  history  or  not,  the  nervous  tem- 
perament is  very  marked  in  most  cases,  and  the  immediate  occasion  of  an 
attack  is  often  found  in  shock,  excitement  or  overwork  of  the  mind.  In 
older  children  a  tendency  to  asthma  is  sometimes  observed.  The  affec- 
tion is  much  more  common  in  city  than  in  country  children,  and  in  those 
with  generally  unhygienic  surroundings.  Apart  from  the  prevalent 
prominence  of  the  gastric  symptoms,  the  migraine  of  childhood  has 
generally  less  distinctive  characters  than  in  the  adult;  owing,  partly,  in 
all  probability  to  the  common  subjective  symptoms,  such  as  visual 
derangement,  noise  in  the  ears,  giddiness,  chilliness,  and  numbness  or 
tingling  of  the  extremities,  being  less  often  expressed.  The  headache, 
too,  is  in  my  experience,  judging  from  the  cases  where  the  patient  is  old 
enough  to  describe  it,  less  often  one-sided  in  onset  than  in  the  adult ;  but 
the  frequency,  even  in  the  adult,  of  a  diffused  frontal  headache  is  certainly 
great  enough  to  render  the  term  "  migraine  "  or  "  hemicrania  "  of  ques 
tionable  propriety.  Light  and  noise  are  as  a  rule  avoided  by  the 
patients,  who  usually  desire  to  lie  down.  The  appetite  is  generally  lost. 
Ail  the  varieties  of  migraine,  with  its  varying  vaso-motor  symptoms  of 
pallor  or  flushing  and  dilatation  or  contraction  of  the  pupils,  may  be 
sometimes  observed  in  children.  I  have  but  seldom  noted  or  suspected 
the  occurrence  of  pyrexia  in  the  paroxysms,  as  mentioned  by  Gowers. 
Mere  pain  may  certainly  be  accompanied  by  a  rise  of  temperature  in 
young  children.  We  must  always  be  on  the  watch  for  otitis  in  cases  of 
apparently  one-sided  headache  in  young  children,  especially  when  it  is 
accompanied  by  pyrexia  and  vomiting. 

The  transient  aphasia  which  occasionally  occurs  in  adults  is  rare  in 
childhood.  I  have  never  observed  it ;  but  in  two  cases  of  well-marked 
migraine,  in  children  that  I  have  seen,  the  frequent  occurrence  of  aphasia 
at  the  outset  has  been  clearly  described  to  me. 

In  making  the  diagnosis  of  migraine  in  children  we  must  be  careful 


328  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

to  exclude  other  causes  of  headache  by  instituting  a  thorough  clinical 
examination  and  inquiry ;  and,  in  those  cases  where  the  headache  is  very 
frequent,  as  well  as  the  very  few  in  which  it  is  almost  constant,  we 
must  search  for  ophthalmoscopic  changes  or  any  localising  or  other 
symptoms  of  brain  disease  before  definitely  pronouncing  the  headache 
to  be  of  non-organic  origin.  Migraine  is  essentially  paroxysmal;  and 
usually  there  are  several  days,  or  more  often  several  weeks,  between  the 
attacks.  The  paroxysms  do  not  as  a  rule  last  so  long  in  childhood  as 
in  adult  life,  being  rarely  of  more  than  a  day's  and  often  but  of  a  few 
hours'  duration. 

The  treatment  of  headache  will  of  course  depend  on  the  cause,  and 
that  of  the  various  symptomatic  forms  is  often  clearly  indicated  and 
successful.  "We  must  examine  for  faulty  visual  accommodation  or 
astigmatism,  and  remedy  any  discovered  defect  by  appropriate  glasses. 
In  any  case  of  apparently  idiopathic  headache,  whether  migrainous 
or  purely  neuralgic  in  nature,  we  may  always  try  the  effect  of  antipyrin 
in  two  doses  of  three  or  four  grains,  with  a  four  hours'  interval,  for 
a  child  of  five  years  old.  This  drug  is  capable  of  notably  alleviating 
attacks  of  migraine  in  numerous  instances,  and  of  completely  arresting 
those  of  pure  neuralgia  in  many  more.  It  is  of  more  importance,  it 
seems  to  me,  in  the  case  of  children,  to  aim  at  antagonizing  the  ten- 
dency to  frequent  headaches,  than  to  cure  the  individual  attacks;  for 
the  longer  this  tendency  lasts  the  more  intractable  it  becomes.  "With 
this  object  the  child  should  be  encouraged  to  be  out  of  doors  as  much 
as  possible,  and  subjected  to  the  best  hygienic  influences.  I  always, 
and  often  successfully,  prescribe  arsenic  and  iron,  with  or  without 
strychnine,  and  very  often  with  cod-liver  oil ;  and  forbid  all  continued 
or  excessive  mental  strain.  The  systematic  administration  of  quinine  is 
occasionally  of  very  good  service ;  and,  according  to  some,  the  same  may 
be  said  of  iodide  of  potassium.  I  have  never  observed  any  benefit  from 
the  bromides,  except  as  sometimes  tending  to  lessen  the  severity  of  an 
attack  when  given  in  a  large  dose.  Dr.  Eustace  Smith  strongly  recom- 
mends the  persistent  use  of  strychnine  and  ergot.  For  the  symptomatic 
treatment  of  the  attacks,  different  drugs  are  unquestionably  efficacious  in 
different  cases ;  and  we  may  be  reduced  to  an  empirical  trial  of  one 
remedy  after  another,  frequently  with  good  success  at  last.  Indian 
hemp,  chloral  hydrate,  chloride  of  ammonium,  gelsemium,  alcohol, 
guaranine,  caffeine,  and  strong  coffee  or  tea,  have  all  been  found  useful 
in  some  cases.  My  own  experience,  both  with  children  and  adults,  is 
quite  in  accord  with  that  of  the  late  Dr.  Fagge,  who,  in  spite  of  the 
acknowledged  tendency  of  this  disease  to  cling  more  or  less  to  a  patient 
through  the  greater  part  of  life,  says  that  migraine  "  if  systematically 
taken  in  hand  "  (and,  I  would  add,  with  due  regard  to  the  circumstances 
of  each  individual  case)  is  very  amenable  to  treatment. 


OTITIS.  329 


CHAPTER    VIII. 

OTITIS. 

Otitis  of  various  kinds,  especially  of  the  middle  ear,  is  common  in 
infancy  and  childhood ;  and,  from  some  of  its  less  generally  recognised 
manifestations,  seems  to  require  separate  consideration  which  may  find 
place  here.  In  many  instances  otitis  causes  much  general  febrile  dis- 
turbance, or,  it  may  be,  symptoms  closely  simulating  meningitis,  without 
any  prominent  sign  of  local  trouble.  Many  cases  of  marked  and  enduring 
pyrexia  in  infants,  mostly  of  a  remittent  but  sometimes  of  a  continued 
form,  and  causing  great  diagnostic  difficulty,  are  due  to  otitis.  Unless 
the  ears  be  examined  with  the  speculum,  when  bulging  of  one  or  both 
membranes  may  sometimes  be  found,  or,  failing  this  evidence,  unless  the 
membranes  be  punctured  and  the  pus  evacuated,  these  cases  may  be  for 
long  undiscovered  and  wrongly  diagnosed  as  enteric  fever,  tuberculosis, 
or  some  other  febrile  condition.  Such  mistakes,  several  times  made  in 
the  wards  at  Shadwell,  have  led  us  of  late  years  to  make  a  careful 
examination  of  the  ears,  or  puncture  of  the  membranes,  in  many  cases  of 
pyrexia  in  young  children  which  were  not  otherwise  explained ;  with  the 
result  of  finding  purulent  otitis  media  in  many  instances,  including 
some  where  nothing  abnormal  Avas  observed  with  the  otoscope,  and 
where  there  was  no  complaint  or  evidence  of  ear-ache.  I  have  been 
much  instructed  by  the  frequent  detection  of  these  cases,  among  both 
in-  and  out-patients,  by  Dr.  E.  B.  Hastings,  recently  resident  medical 
officer  at  Shadwell. 

Cases  of  both  catarrhal  and  purulent  otitis  media  seem  to  be  fre- 
quently set  up  by  extension  of  naso-pharyngeal  inflammation  along  the 
Eustachian  tube,  or  by  tonsillitis  or  post-nasal  growths ;  and  are  encour- 
aged by  any  blocking  of  the  nares  which  facilitates  the  forcible  entry 
of  air  or  liquids  into  the  tympanic  cavity  during  coughing,  swallow- 
ing, or  vomiting.  In  children  unable  to  speak  a  catarrhal  inflammation 
of  the  tympanum  may  occur,  of  sufficient  importance  to  cause  con- 
siderable and  prolonged  febrile  disturbance,  without  definite  evidence  of 
local  disease,  and  with  no  subsequent  discharge  of  pus.  In  severe 
cases,  however,  pus  is  often  discharged  after  a  while,  with  subsidence  of 
symptoms.  Otitis,  therefore,  should  always  be  thought  of  in  otherwise 
inexplicable  attacks  of  fever ;  and  the  proof  of  its  occurrence  is  of  course 
very  strong  when  there  is  constant  crying,  or  evidence  of  local  pain  or 
deafness,   which  can  usually  be  discovered  in  older  children.      These 


330  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

latter  cases,  of  plain  nature,  are  best  treated  at  first  with  the  continuous 
application  of  dry  heat  to  the  ear  by  means  of  bran-poultices,  which  will 
frequently  relieve  the  pain  in  a  short  time.  The  tympanum  may  also  be 
inflated  by  the  Politzer  method.  If,  however,  persistence  of  symptoms, 
and  more  especially  rigors  and  bulging  of  the  membrane,  point  to  a 
purulent  inflammation,  the  membrane  should  be  at  once  incised.  In  the 
cases  where  only  fever  is  present,  and  careful  observation  has  excluded 
other  causes  as  far  as  possible,  the  membrane  or  membranes  should 
certainly  be  punctured  if  there  be  any  oozing  or  bulging ;  and,  even  in 
the  absence  of  these  signs,  this  operation  should  not  be  long  delayed  in 
otherwise  inexplicable  cases  where  the  fever  is  persistent  and  high. 
Properly  performed  it  does  little  or  no  harm,  even  when  its  result  dis- 
proves the  suspicion  of  ear-mischief.  Whether  the  opening  is  spon- 
taneous or  surgical,  insufflation  of  the  powder  of  boric  acid  or  iodoform 
should  be  practised,  and  the  meatus  carefully  cleaned  and  stuffed  with 
antiseptic  wool. 

Purulent  otitis  is  not  very  often  the  result  of  simple  catarrh,  but  is 
exceedingly  frequent  after  many  of  the  exanthemata,  especially  scarlatina 
or  measles,  and  often  begins  insidiously.  It  occurs  also  after  diphtheria, 
sometimes  after  enteric  fever,  and  in  association  with  any  form  of  cere- 
bral meningitis.  Especially  with  meningitis  the  inflammation  seems  to 
begin  in  both  internal  ears,  and  may  or  may  not  affect  the  tympanum. 
It  is  certain  that  purulent  double  otitis  media  often  occurs  in  con- 
nexion with  meningitis,  tubercular  or  otherwise,  without  any  disease 
of  the  petrous  bone,  and  is  then  probably  to  be  regarded  not  as  causal 
but  as  concomitant  with  the  wider  affection.  Otitis  interna  may  be 
evidenced  by  vomiting  and  cerebral  symptoms,  especially  giddiness  and 
unsteady  gait;  and  results  in  complete  deafness.  The  deafness  which 
is  observed  after  recovery  from  apparent  meningitis  is  probably  often 
due  to  this  affection. 

It  must  be  remembered,  in  connexion  with  the  clinical  importance  of 
otitis,  that,  among  several  other  micro-organisms  found  in  association 
with  the  lesion,  the  "  diplococcus  pneumonias "  has  been  observed.  Some 
cases  of  this  disease  may  thus  be  probably  regarded  as  instances  of 
independent  specific  infection. 

Disease  of  the  petrous  bone  is  well  known  as  a  sequel  of  otitis,  and 
often  causes  purulent  meningitis,  cerebral  or  cerebellar  abscess,  throm- 
bosis of  the  lateral  sinus,  or  facial  paralysis. 

In  all  cases  of  chronic  otorrhcea  sedulous  attempts  should  be  made  to 
check  the  affection  by  antiseptic  and  astringent  injections.  For  this 
purpose  a  lotion  of  sulphate  of  zinc  or  borax,  or  both,  of  the  strength  of 
five  grains  to  the  ounce  of  water,  is  useful;  and,  in  obstinate  cases,  a 
similar  or  somewhat  weaker  solution  of  silver  nitrate. 


TETANUS.  33  I 


CHAPTER    IX. 

TETANUS. 

Although  rare,  or  at  least  rarely  coming  under  medical  observation,  in 
England,  tetanus  in  infants  is  a  disease  of  such  importance  and  fatality 
as  to  necessitate  a  short  notice.  I  consider  it  in  connexion  with  nervous 
disorders  because  of  its  prominent  symptoms.  Present  knowledge  as  to 
its  aetiology  almost  conclusively  shows  that  it  is  strictly  an  infectious 
disease.  Among  the  large  number  of  young  babies  admitted  into  the 
Shadwell  Hospital  during  the  last  eighteen  years  or  more  I  have  seen 
but  very  few  examples,  apart  from  occasional  traumatic  cases  under 
surgical  care.  It  would  appear  from  statistics  that  traumatic  tetanus  is 
on  the  whole  comparatively  not  rare  in  children  beyond  infancy,  and 
that  it  is  most  frequent  during  early  youth.  Nothing  need  be  said  con- 
cerning this  form  of  the  affection,  which  is  described  by  all  systematic 
writers,  except  that  it  occurs  after  punctured,  lacerated  and  contused, 
rather  than  incised,  wounds ;  that  dirt  in  the  wound  is  a  strongly 
favouring  factor ;  and  that  modern  research  has,  practically,  proved  that 
the  essential  cause  is  the  operation  of  the  specific  bacillus  of  Nicolaier, 
introduced  at  the  seat  of  the  lesion.  This  bacillus,  several  excellent 
specimens  of  which  were  shown  at  the  London  International  Congress 
of  Hjgiene  in  1 891,  is  marked  by  one  knob-shaped  extremity  caused  by 
the  development  of  ovoid  spore-formation.  Of  the  so-called  idiopathic 
or  non-traumatic  tetanus,  which  may  occur  at  any  age  and  numbers  more 
recoveries  than  the  commoner  traumatic  form,  it  can  only  be  said  that  it 
is  probably  also  specific  in  its  origin ;  the  germ  being  introduced  in  other 
ways,  possibly  by  the  mouth,  and  its  poison  acting  under  less  favourable 
conditions.  The  high  temperature  that  marks  some  cases  is  almost  surely 
due  to  affection  of  the  nerve-centres  which  are  concerned  with  the  regu- 
lation of  the  body-heat. 

"Tetanus  neonatorum"  is  almost  certainly,  considering  both  its  similar 
symptomatology  and  its  favouring  conditions,  of  the  same  pathology  as 
the  tetanus  of  later  age.  Tetanus  in  animals  has  been  produced  by 
Beumer  by  inoculation  with  inflammatory  material  from  the  umbilicus  of 
a  fatal  case  of  tetanus  neonatorum.  It  occurs  mostly  in  association  with 
dirt  and  neglect,  with  injury  or  inflammation  of  the  umbilical  cord,  and 
with  lesions  during  birth  ;  and  is  apparently  favoured  by  damp  and  cold. 
The  symptoms  usually  appear  between  four  and  eight  days  after  birth ; 
and  it  has  been  remarked  by  Niemeyer  that  its  limits  of  appearance  are 


332  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

between  the  first  and  fifth  day  after  the  separation  of  the  remains  of  the 
umbilical  cord.  The  disease  is  fatal  in  about  90  per  cent,  of  all  cases ; 
and  death  usually  takes  place  between  four  or  five  hours  and  three  days 
after  the  onset  of  symptoms. 

In  the  diagnosis  of  tetanus,  other  than  that  of  the  new-born,  strychnia 
poisoning  must  of  course  be  thought  of ;  and  perhaps  especially  now,  when 
strychnia  is  so  often  given  to  children.  The  spasms  of  strychnia  poison- 
ing begin  as  a  rule  suddenly,  not  gradually,  as  in  tetanus ;  the  arms  are 
involved ;  the  jaws  are  not  affected  until  late  in  the  paroxysm  instead  of 
at  the  beginning ;  and  the  seizures  are  usually  separated  by  periods  of 
complete  general  flaccidity  of  all  muscles.  From  tetany  the  diagnosis  is 
mostly  of  no  difficulty ;  the  hands  and  feet  only  being  tonically  con- 
tracted in  this  disease  of  infancy,  which,  as  we  have  seen,  is  closely  allied 
to  the  convulsive  condition. 

The  earlier  the  symptoms  appear  in  traumatic  cases,  the  worse  is  the 
prognosis.  The  non-traumatic  instances  are  much  more  hopeful  than 
others.  In  "  tetanus  neonatorum,"  which  is  in  all  respects  comparable 
to  traumatic  tetanus,  the  only  slight  element  of  hope  is  the  duration  of 
the  symptoms  beyond  two  or  three  days.  Cases  of  tetanus  with  wounds 
should  be  treated  in  all  respects,  both  as  regards  surgical  dressings  and 
subsequent  disinfection  of  bed  and  bedding,  on  the  principles  applicable  to 
infectious  diseases.  The  wound  should  be  freely  incised  and  thoroughly 
cleansed  with  an  antiseptic.  In  non-traumatic  cases  it  has  been  suggested, 
and  it  is  probably  advisable,  to  give  an  initial  purge  and  such  an  antiseptic 
as  salicylic  acid.  Forced  feeding  by  a  tube  will  be  necessary,  and  alcohol 
should  be  given  from  time  to  time,  as  well  as  bromide  of  potassium  with 
chloral  in  as  full  doses  as  can  be  safely  borne.  This  can  be  judged  of  only 
by  its  effect,  and  therefore  small  doses  should  be  administered  at  first.  For 
the  same  sedative  purpose  inhalation  of  chloroform,  or  morphia  injec- 
tions, may  be  tried  with  great  caution.  Calabar  bean  has  been  extolled 
by  some  and  rejected  by  others.  It  was  useless  in  the  few  cases  of  teta- 
nus neonatorum  where  I  tried  it,  as  it  certainly  is  in  traumatic  tetanus. 
In  one  case  of  so-called  idiopathic  tetanus,  in  a  boy  of  ten  years  old,  re- 
covery took  place  while  calabar  bean  was  being  taken ;  but  improvement 
had  already  set  in  before  the  drug  was  prescribed.  The  best  mode  of 
administration  is  by  hypodermic  injection  of  eserine,  beginning  with 
TJ-¥th  of  a  grain. 


SECTION   V. 
DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


SECTION  V.— DISEASES  OF  THE  RESPIRATORY 

SYSTEM. 

I  have  thought  it  ■well,  for  practical  purposes,  to  depart  in  some  par- 
ticulars from  a  strictly  systematic  or  anatomical  classification  of  the 
disorders  to  be  treated  of  in  this  section.  The  chief  symptoms  pointing 
to  disorder  of  the  respiratory  passages  are  frequent  or  laboured  breathing, 
impairment  or  loss  of  voice,  cough,  and  expectoration.  Some  of  these 
symptoms  may  occur  singly  or  in  marked  prominence,  or  in  varying 
proportions  and  combinations.  Affections  of  the  larynx  are  marked  by 
alteration  or  absence  of  voice  or  by  dyspnoea  in  all  degrees ;  persistent 
cough  becoming  prominent  in  relation  to  the  amount  of  involvement  of 
the  trachea  and  larger  bronchi.  The  special  symptom  of  affection  of  the 
trachea  and  larger  bronchi  is  cough  ;  dyspnoea  being  marked  when  the 
larynx  or  smaller  bronchi  are  much  engaged.  The  leading  characteristic 
of  disease  of  the  smaller  hronchi  and  the  air-cells  is  dyspnoea  or  hurried 
breathing ;  cough  being  sometimes  marked,  but  often  insignificant,  and 
occasionally  absent.  Proceeding,  then,  partly  on  a  clinical  and  parti}' 
on  a  regional  basis  of  classification,  I  shall  treat  first  of  diseases  of  the 
larynx  and  upper  air-passages ;  next  of  the  affections  of  the  trachea  and 
larger  bronchi,  including  chronic  bronchitis ;  and  lastly  of  those  of  the 
smaller  bronchi  and  the  lungs.  The  subjects  included  under  these  head- 
ings will  frequently  overlap  one  another ;  but  no  one  strict  principle  of 
classification,  be  it  anatomical,  serological  or  clinical,  is  free  from  these 
objections,  and  the  arrangement  I  have  chosen  has  the  advantage  of 
calling  attention  to  what  appear  to  me  the  main  clinical  groups  of 
respiratory  disorders. 

In  all  cases  where  the  symptoms  point  to  affections  of  this  class  it  is 
desirable  to  examine  the  whole  body  of  the  child  as  conq^letely  as  possible 
at  the  outset.  By  this  practice  many  simultaneous  observations  may  be 
made,  and  many  blunders  prevented.  The  nature  of  the  breathing,  the 
retraction,  if  any,  of  the  soft  parts  of  the  thorax  and  neck,  the  state  of 
the  abdomen,  the  appearance  of  the  skin,  and  the  amount  of  general 
nutrition  may  thus,  among  other  points,  be  rapidly  noted  by  eye  or  hand, 
and  we  may  at  once  learn  that  we  have  to  do  with  something  more  than 
disease  localised  in  the  thorax.  Examination  of  the  fauces  should  never 
be  omitted. 

335 


33^  DISEASES  OE  THE  RESPIRATORY  SYSTEM. 

Considering  the  frequency  of  general  diseases,  infectious  or  otherwise, 
being  prominently  evidenced  by,  or  complicated  or  merely  coincident 
with,  the  symptoms  of  respiratory  trouble,  the  value  of  this  caution  as 
to  exhaustive  examination  is  manifest.  I  have  frequently  known  neglect 
of  it,  both  in  my  own  practice  and  that  of  others,  either  prevent  or  post- 
pone the  discovery  of  exanthematous  or  other  disorders.  Enteric  fever 
has  thus  been  missed,  and  marked  deformities,  especially  those  of  rickets, 
passed  over.  More  than  once  have  I  seen  diphtheria  ignored,  with  de- 
plorable results,  by  omission  to  examine  the  throat  and  nose  in  cases,  not 
only  of  general  febrile  illness,  but  also  of  coincident  and  even  chronic 
respiratory  disease.  It  must  then  be  insisted  on  that  the  most  careful 
clinical  examination  be  made  of  the  thorax  and  the  whole  body  as  soon 
as  possible  in  every  case.  It  may  frequently,  indeed,  be  made  then, 
once  for  all. 

In  examining  a  young  child's  chest  there  are  certain  points  to  be 
remembered  that  may  escape  those  who  are  inexperienced.  It  is  not 
my  intention  to  dwell  long  on  the  methods  of  handling  or  speaking  to 
children,  for  I  believe  that  his  own  tact  and  a  few  trials  will  enable  any 
teachable  man  to  adapt  the  mode  of  his  examination  to  the  age  and 
idiosyncrasy  of  any  of  his  patients.  Although  in  some  cases  much  can 
be  done  as  regards  auscultation  with  the  ear  alone,  the  stethoscope  should 
generally  be  used  for  the  sake  of  accuracy ;  and,  notwithstanding  the 
child's  possible  crying  and  restlessness,  good  results  will  soon  be  attained 
by  practice.  It  is  well  to  percuss  when  the  child  is  quiet ;  for  noise  and 
movement  interfere  far  more  with  percussion  than  auscultation.  It  is 
consequently  sometimes  better  to  percuss  last  in  the  order  of  examina- 
tion, when  the  child  may  have  become  reconciled  to  the  procedure.  I 
believe  it  is  always  better  to  percuss  lightly  with  one  finger  on  another, 
considering  the  ready  awakening  of  the  general  chest  resonance  that 
follows  on  more  vigorous  strokes.  More  definite  and  brilliant  results 
of  merely  local  diagnosis  may  occasionally  be  attained  by  the  use  of 
plessor  and  plessimeter ;  but  these,  I  am  sure,  can  always  be  practically 
dispensed  with,  especially  in  the  case  of  children.  The  transmission 
of  morbid  sounds  from  the  affected  to  the  other  side  is  certainly  much 
more  marked  in  children  than  adults ;  but  care  and  a  good  ear  will 
usually  prevent  erroneous  conclusions.  "  Puerile  "  breathing,  which  is  so 
familiar  in  name  to  the  student,  is  very  frequently  forgotten  in  practice ; 
and  the  normally  harsh  and  sometimes  almost  grating  sound  of  inspira- 
tion, as  well  as  the  frequently  somewhat  prolonged  expiration  in  young 
children,  is  not  seldom  mistaken  for  a  sign  of  disease.  Several  times 
have  I  known  slight  pleural  effusions  give  rise  to  the  diagnosis  of  disease 
in  the  opposite  lung.  It  is  essential,  considering  the  great  frequency  of 
bronchial  breathing  in  young  children  without  any  chest  affection,  to  be 


AFFECTIONS  OF  THE  NOSE.  3  37 

especially  careful  in  the  comparative  examination  of  both  sides  of  the 
chest  before  pronouncing  on  the  existence  of  disease.  Another  difficulty 
is  constantly  presenting  itself  to  the  beginner  in  percussing  the  chests  of 
infants,  owing  to  the  great  difference  in  note  frequently  observed  on  the 
two  sides  when  there  is  nothing  the  matter.  This  is  due  to  the  varying 
amount  of  air  entering  the  lungs  from  the  still  incompletely  regulated 
action  of  the  nervous  apparatus  concerned  in  respiration.  We  must 
also  remember  here  that  the  respiratory  rhythm  in  infancy  is  often 
very  irregular  from  the  same  cause.  It  is  only  at  a  later  time  that  this 
irregularity  becomes  a  definite  sign  of  disease.  In  percussing  the  chest 
we  must  not  rely  on  comparative  observations  made  during  inspiration 
on  one  side  and  expiration  on  the  other,  for  such  a  procedure  may  lead 
to  surprisingly  false  results.  It  is  quite  common  to  note  prolonged 
inspiratory  holding  of  the  breath  by  infants  during  examination,  and  also 
long  pauses  after  expiration.  Much  may  be  learned  from  listening  to 
the  long  inspiration  which  follows  the  pause.  The  type  of  infantile 
breathing  is  diaphragmatic  and  mainly  nasal,  oral  breathing  being  a 
later  acquisition ;  and  the  frequency  of  the  respiratory  act  is  great, 
gradually  decreasing  till  it  reaches  the  normal  adult  standard  about  the 
age  of  two  years.  In  every  case  the  results  of  percussion  and  of  auscul- 
tation must  reciprocally  check  one  another ;  and  it  will  often  be  well  to 
postpone  our  diagnosis  until  we  can  repeat  our  examination. 


OHAPTEE  I. 

AFFECTIONS    OF    THE   NOSE. 

The  nasal  passages  are  subject  to  various  diseases  which  more  or  less 
interfere  with  respiration. 

Nasal  catarrh,  whether  due  to  chill  or  infection,  may  be  observed  at 
all  ages,  but  is  not  common  in  very  early  infancy.  It  may  be  the  herald 
of  a  laryngeal,  tracheal,  or  bronchial  and  broncho-pneumonic  catarrh, 
and  is  sometimes  a  very  early  indication  of  measles.  In  diphtheria,  too, 
it  may  be  an  early  symptom,  and,  when  marked,  is  of  bad  omen  both  in 
that  disease  and  in  scarlatina.  In  every  case  of  nasal  catarrh  the  child 
should  be  stripped,  and  the  throat  and  chest  carefully  examined. 

The  chronic  form  of  nasal  catarrh  is  often  seen  in  scrofulous  children, 
and  is  generally  accompanied  by  other  symptoms,  such  as  dermatitis  or 
mucous  inflammations,  especially  about  the  eye  and  ear,  and  swelling 
of  the  cervical  glands.  It  may  go  on  to  ulceration  of  the  mucosa 
and  disease  of  the  bone,  giving  rise  to  ozoena  with  purulent  or  sanious 

Y 


338  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

discharge  and  all  degrees  of  foetor.  One  of  the  commonest  forms  of 
chronic  nasal  mischief  is  the  syphilitic;  and  persistent  nasal  discharge 
in  infants,  whether  purulent  or  not,  should  always  he  at  least  suspected 
to  be  of  this  nature,  even  if  it  he  not  accompanied  by  the  characteristic 
ulcerations  or  cracks  between  the  nostrils  and  upper  lip. 

Owing  to  the  predominantly  nasal  character  of  infantile  breathing,  any 
blocking  of  the  nares  gives  rise  to  more  or  less  dyspnoea  and  impedes  the 
act  of  sucking. 

Acute  nasal  catarrh  should  be  treated  by  confinement  to  bed  and 
warmth ;  and  in  marked  cases,  in  view  of  the  possible  sequel  of  laryngitis, 
severe  bronchitis,  or  broncho-pneumonia,  a  steam-tent  should  inclose  the 
bed.  In  chronic  cases  anti-syphilitic  treatment  should  usually  be  tried. 
I  can  confirm  the  statement  of  Goodhart  that  a  course  of  grey  powders 
seems  sometimes  to  be  of  use  in  chronic  "  snuffles,"  even  when  there  is 
no  further  evidence  of  syphilis.  It  is  advisable,  in  all  cases  of  chronic 
nasal  catarrh,  to  keep  the  nostrils  clean  by  local  treatment,  painting  them 
with  the  glycerine  of  borax  or  of  tannic  acid,  or  syringing  them  with  a 
Aveak  solution  of  zinc  sulphate  (gr.  iij.  to  the  ounce)  or  of  silver  nitrate 
(gr.  i.  to  the  ounce).  Any  detected  or  suspected  disorder  underlying  the 
symptom  should  be  treated  by  appropriate  dietetic  and  hygienic  remedies. 

Over-growth  of  the  glandular  tissue  at  the  upper  part  of  the  pharynx 
and  in  the  posterior  nares  has  been  for  some  time  recognised  as  connected 
with  a  definite  set  of  symptoms,  and  is  of  frequent  occurrence.  It  is 
generally  known  under  the  name  of  "  nasal  adenoids "  or  adenoid 
vegetations.  Often  met  with  in  conjunction  with  tonsillar  enlargement, 
it  may  nevertheless  be  found  alone,  and  causes  snoring  during  sleep, 
nasal  voice,  and  a  vacant  expression  mainly  due  to  the  habitually  open 
mouth.  There  is  frequently  a  discharge  of  mucus  and  blood  into  the 
mouth,  and  more  or  less  constant  headache. 

These  growths,  of  various  size  and  shape,  sessile  or  pedunculated,  can 
be  felt  by  the  finger  passed  behind  the  palatal  arch ;  and  their  presence 
may  often  be  guessed  from  the  open  mouth  and  facial  expression  above 
mentioned.  This  affection  is  often  connected  with  the  scrofulous  con- 
dition, and  seems  to  follow  on  repeated  catarrh ;  but  in  many  cases  it 
appears  in  very  early  life  without  discoverable  exciting  cause,  and  no 
serological  generalisation  can  be  made. 

The  best  treatment  is  the  careful  removal  of  the  growths  by  the 
finger-nail  or  an  instrument  invented  for  the  purpose ;  and  subsequent 
cauterisation  of  the  part  with  nitrate  of  silver  is  probably  advisable. 
Strikingly  good  results  are  thus  obtained.  The  operation  should  not 
be  delayed ;  for,  among  other  untoward  consequences  of  this  affection, 
chronic  catarrh  of  the  middle  ear  and  purulent  discharge  from  a  ruptured 
tympanum  may  follow  on  long  neglect. 


LARYNGEAL  AND  LARYNGOTRACHEAL  AFFECTIONS.        3  39 


CHAPTER  II. 

LARYNGEAL    AND    LARYNGO-TRACHEAL    AFFECTIONS. 

Larntgeal  affections  are  marked  clinically  by  altered  voice  with,  more 
or  less  cough,  by  dyspnoea,  or  by  a  combination  of  these  symptoms.  In 
very  early  life  their  pre-eminent  characteristic  is  dyspnoea,  owing  to  the 
narrowness  of  the  infantile  glottis,  and  to  a  liability  to  general  spasm 
which  especially  affects  the  laryngeal  muscles.  A  comparatively  slight 
inflammation  of  the  laryngeal  mucosa  may  thus  materially  impede  the 
breathing,  inspissated  secretion  alone  being  able  to  cause  considerable 
obstruction  ;  and  severe  dyspnoea  may  occur  in  cases  where  the  spasmodic 
habit  is  marked,  even  apart  from  the  exciting  cause  of  demonstrable 
affection  of  the  laryngeal  structures. 

Excluding  certain  sources  of  laryngeal  trouble,  presently  to  be  glanced 
at,  and  mostly  with  no  marked  peculiarity  in  early  life,  we  shall  find  that 
the  laryngo-tracheal  affections,  which,  from  their  special  incidence  on  child- 
hood, must  chiefly  engage  our  attention,  fall  clinically  into  three  groups  : 
the  first  being  characterised  by  pure  spasm ;  the  second  by  spasm  arising 
from  local  affection  of  the  larynx,  however  slight ;  and  the  third  by  direct 
obstruction  of  the  upper  air-passages  from  acute  and  chronic  inflammatory 
changes,  membranous  or  otherwise. 

Before  discussing  these  groups,  which,  as  will  at  once  be  seen,  have 
in  practice  no  absolute  line  of  demarcation  between  them,  I  briefly 
touch  upon  the  following  causes  of  greater  or  less  stenosis  of  the  larynx 
and  trachea,  which  must  be  borne  in  mind  for  the  sake  of  diagnosis. 
Warty  growths  (papillomata),  though  not  very  common  in  childhood, 
are  probably  more  so  than  is  generally  taught,  judging  from  the  results 
of  post-mortem  examinations.  They  may  occur  in  very  young  infants ; 
and  the  symptoms  may  begin  either  suddenly  or  insidiously,  cases  of  the 
first  kind  being  most  liable  to  mistaken  diagnosis.  The  voice  is  im- 
paired, and  all  degrees  of  remittent  or  continuous  dyspnoea  may  be 
observed.  Laryngoscopy,  the  only  means  of  making  a  positive  diag- 
nosis, is  always  difficult  and  mostly  impossible  in  quite  young  children ; 
and  here  emphatically  so  from  the  usually  concomitant  pharyngeal 
catarrh  and  irritability.  This  condition  may  be  suspected  from  the 
absence  of  fever,  the  long  continuance  of  the  symptoms,  and  the 
evidence  of  the  obstruction  being  solely  laryngeal.  When  demonstrated, 
the  growths  should  be  removed  if  possible ;  and,  when  the  symptoms  are 
severe  and  obstinate,  tracheotomy  should  certainly  be  performed  while 


34-0  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

the  diagnosis  is  yet  incomplete.     The  growths  may  then  perhaps  he  at 
least  partially  removed,  or  thyrotomy  may  subsequently  he  performed. 

Foreign  bodies  may  obstruct  the  windpipe,  causing  paroxysmal  dysp- 
noea and,  unless  soon  otherwise  expelled,  indicating  tracheotomy  even 
before  the  development  of  urgent  symptoms,  when  the  nature  of  the  case 
is  clear.  In  some  cases  the  body  becomes  lodged  in  one  bronchus,  giving 
rise  to  signs  of  bronchitis  and  of  deficient  entry  of  air  on  one  side. 

Laryngeal  oedema,  from  inflammation  or  ulceration  of  the  neighbouring 
pharyngeal  structures,  may  seriously  impede  breathing,  as  also  may  para- 
lysis of  one  or  both  abductors.  Such  incidents  may  occur  in  the  course 
of  tuberculosis,  syphilis,  measles,  scarlet  fever,  diphtheria,  small-pox,  and 
enteric  or  other  fevers. 

Pharyngeal  abscesses  or  enlarged  glands,  such  as  thyroid,  thymus, 
or  bronchial,  may  narrow  the  laryngo-tracheal  tube ;  and  even  the  most 
careful  examination  and  study  of  these  cases  may  not  seldom  fail  us 
when  seeking  for  an  accurate  diagnosis.  A  pharyngeal  abscess  should  of 
course  be  rarely,  if  ever,  missed ;  but  the  following  case,  which  happened 
at  the  East  London  Hospital  for  Children,  shows  how  difficult  it  may  be 
to  distinguish  the  effects  of  a  caseous  gland  from  that  of  a  foreign  body 
in  the  trachea.  Sudden  dyspnoea  occurred  in  a  child  of  one  year  old 
in  apparently  perfect  health,  who  was  at  once  brought  to  the  hospital. 
Tracheotomy  was  performed  by  Dr.  Hastings,  giving  slight  temporary 
relief ;  but  death  followed  in  an  hour  and  a  half  from  the  first  symptoms 
of  the  attack.  At  the  post-mortem  a  caseous  gland,  which  had  ulcerated 
into  the  trachea,  was  found  just  above  the  bifurcation,  entirely  occluding 
one  bronchus. 

Generally  speaking,  for  a  correct  diagnosis  of  the  causes  of  laryngo- 
tracheal obstruction,  the  history  of  the  case  must  be  carefully  studied ; 
and  any  concomitant  symptoms,  such  as  fever  or  other  constitutional  dis- 
turbance, must  be  taken  into  account.  The  diagnosis  of  obstruction  of 
the  upper  air-passages  from  that  caused  by  extensive  involvement  of  the 
bronchial  tree  is  not  always  to  be  made  at  first  sight,  especially  when 
clearness  of  voice  excludes  marked  laryngeal  mischief ;  for  extreme  re- 
traction of  the  soft  parts  of  the  thorax  may  be  seen  in  both  affections. 
Stridor,  however,  points  to  tracheal  obstruction  ;  and,  especially  when  the 
larynx  is  involved,  as  in  membranous  inflammation,  it  is  expiratory  as 
well  as  inspiratory.  Loss  of  voice  and  hoarse  or  whispering  cough  are 
pathognomonic  of  laryngeal  trouble. 

Laryngismus  Stridulus. 

Under  this  title  I  would  include  all  laryngeal  attacks  in  children 
which  are  strictly  paroxysmal,  the  voice  and  breathing  being  unaffected 
in  the  intervals.     A  very  large  majority  of  these  cases  are  undoubtedly 


LARYNGEAL  AND  LARYNGOTRACHEAL  AFFECTIONS.       34  I 

referable  to  instability  of  the  nervous  mechanism,  and  are,  further,  usually 
associated  with  rickets.  Some  cases,  unconnected  with  rickets  or  evident 
convulsive  tendency,  are  probably  due  to  a  recurvation  of  the  epiglottis, 
causing  a  close  approximation  of  the  ary-epiglottic  folds,  as  shown  by 
Dr.  Lees  in  a  case  which  died  from  some  other  cause ;  and  still  others 
may  possibly  be  due,  as  was  once  widely  believed,  to  reflex  irritation 
from  the  pressure  on  the  vagus  by  enlarged  mediastinal  glands.  It  must, 
however,  be  borne  in  mind  that  the  essentially  paroxysmal  nature  of 
laryngismus  is  not  well  accounted  for  by  this  last  supposed  exciting 
cause,  and  that  the  symptom  is  but  rarely  accompanied  by  either  clinical 
or  anatomical  evidence  of  this  condition.  The  special  nervous  proclivity 
which  confessedly  underlies  most  cases  of  laryngismus  is  probably  a  neces- 
sary element  in  the  production  of  the  spasmodic  attacks  which  have  been 
referred  to  such  peripheral  excitation. 

True  laryngismus  is  mainly  to  be  studied  in  rickety  children  under 
two  years  old,  although  the  tendency  may  sometimes  be  observed  at  a 
somewhat  later  time.  It  is,  strictly  speaking,  a  nervous  affection — a  dis- 
turbance of  the  respiratory  rhythm.  In  its  simplest  form  it  is  marked 
by  glottic  spasm,  evidenced  by  a  suspension  of  breathing  and  pallor  or 
blueness  of  the  face,  followed,  after  a  while,  by  a  more  or  less  pronounced 
crowing  inspiration.  The  attack  is  frequently  observed  on  the  child's 
awakening  from  sleep.  Excitement  indeed,  such  as  a  fit  of  crying,  often 
produces  it •  but  in  most  cases,  as  in  many  allied  spasms,  the  immediate 
occasion  of  the  discharge  of  the  unstable  nerve-centre  is  not  discoverable. 
In  many  cases,  perhaps  in  most,  the  careful  observer  will  note  some 
evidence  of  further  spasm,  such  as  twitchings  of  the  muscles  of  the  face ; 
and  in  the  severe  forms  general  convulsions  are  marked.  Here  the  child 
throws  itself  back  in  evident  distress,  the  neck  and  back  are  arched,  the 
chest  and  abdomen  stiff,  the  eyes  turned  up,  and  the  limbs  are  tonically 
contracted  with  thumbs  doubled,  fingers  extended,  wrists  flexed,  legs 
thrust  out,  soles  turned  in,  and  toes  stretched  apart.  There  is  often,  too, 
discharge  from  rectum  and  bladder.  After  a  few  seconds  the  opening  of 
the  glottis  is  accompanied  by  the  crowing  breath.  The  nervous  basis  of 
the  disorder  is,  further,  well  exemplified  by  the  laryngismal  attacks  alter- 
nating, in  some  cases,  with  slight  paroxysms  of  apnoea  and  rigidity  alone, 
without  glottic  symptoms,  such  attacks  being  referable  to  diaphragmatic 
spasm.  In  some  few  instances  death  may  occur  in  prolonged  spasm ;  and, 
as  a  result,  the  brain  and  membranes  may  be  seen  gorged  with  blood 
after  death. 

It  is  probable,  though  not  certain,  that  some  disturbance  of  the  stomach 
or  bowels,  or  occasionally  dentition  or  other  peripheral  excitants,  may 
occasion  this  and  other  convulsive  phenomena ;  but  such  causes  are 
not  necessary  for  the  due    explanation  of   the  nervous  disorder.     Dr. 


342  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

Gee  has  made  the  valuable  observation,  which  most  experience  confirms, 
that  laryngismus  is  most  common  in  the  winter  months,  and  attributes 
it  to  the  nervous  conditions  encouraged  by  close  confinement  and  bad 
ventilation. 

The  main  difficulty  in  diagnosis  is  the  possible  confusion  of  laryn- 
gismus with  the  results  of  a  foreign  body  in  the  air-passages ;  but  time 
soon  removes  the  doubt.  After  the  attack  the  voice  is  clear,  and  all 
symptoms  vanish.  The  spasmodic  dyspnoea  which  may  result  from 
recurvation  of  the  epiglottis  or  other  infantile  peculiarity  is  not  severe ; 
but  it  is  more  continuous,  or  is  at  least  more  frequently  excited  by  any- 
thing that  hurries  the  breathing.  This  condition  appears  always  to  right 
itself  with  increasing  age. 

For  treatment  the  sufferer  from  laryngismus  should  be  placed  in  a 
hot  bath.  Should  the  attacks  be  frequent,  the  bromides,  and  preferably 
the  ammonium  salt,  should  be  given ;  and  the  more  recurrent  they  are 
the  greater  is  this  indication.  In  general  and  repeated  convulsions  the 
inhalation  of  chloroform  is  sometimes  useful  between  the  paroxysms ; 
and  morphia  may  be  cautiously  given  with  good  effect.  The  rectal 
injection  of  two  or  three  grains  of  chloral  hydrate,  with  or  without  some 
bromide  of  potassium,  has  been  often  found  very  successful.  Artificial 
respiration  should  be  tried  when  the  period  of  apnoea  is  prolonged ;  and 
the  finger  should  be  passed  down  to  the  epiglottis  in  case  the  tip  of 
that  body  be  imprisoned  between  the  posterior  wall  of  the  larynx  and 
the  pharynx,  as  has  been  pointed  out  by  some  observers.  For  the  rest, 
the  most  important  part  of  the  treatment  is  that  of  rickets  generally ; 
and  special  care  should  be  taken  to  furnish  the  child  with  plenty  of 
light,  fresh  air,  and  good  nourishment,  so  indispensable  for  the  adequate 
supply  of  nerve-force.  A  series  of  cold  or  cool  baths  is  a  good  pro- 
phylactic ;  and  cod-liver  oil  and  iron  are  often  advisable.  All  known 
or  supposed  exciting  causes  should  be  avoided  or  counteracted,  and 
especially  chills,  which,  by  causing  catarrh  of  the  air-passages,  may  also 
occasion  this  particular  spasm. 

Glottic  Spasm  with  Laryngeal  Catarrh. 

In  this  class  of  cases,  frequently  styled  "false  croup"  or  "stridulous 
laryngitis,"  the  symptoms  of  laryngeal  spasm  predominate,  and  the 
attacks,  which  often  begin  quite  suddenly,  are  apt  to  be  confused  with 
pure  laryngismus.  But  there  is  always  evidence,  however  slight,  of 
some  preceding  catarrh  ;  and  vocal  hoarseness,  perhaps  with  some  disturb- 
ance of  breathing,  is  noticeable  in  the  intervals  of  the  attacks.  The 
subjects  of  this  affection  are  usually  children  from  about  one  and  a  half 
to  five  or  six  years  old,  their  liability  to  it  almost  always  showing  itself 


LARYNGEAL  AND  LARYNGOTRACHEAL  AFFECTIONS.        343 

quite  early ;  and  there  are  frequently  symptoms  of  nerve-disorder  other 
than  this  tendency  to  spasm.  The  laryngeal  affection  is  to  be  traced, 
however,  to  a  strictly  catarrhal  origin,  which  can  be  demonstrated  laryn- 
goscopically  in  older  patients,  and  is  evidenced  by  the  hoarseness  and 
cough  which  may  remain  after  the  spasmodic  symptom  has  disappeared. 
The  attack  as  a  rule  begins  suddenly  and  most  often,  as  in  laryngismus, 
at  night ;  the  symptoms  of  bronchial  or  nasal  catarrh,  which  always 
accompany  and  often  precede  it,  being  generally  unobserved  or  neglected. 
It  may  be  of  great  severity  and  cause  much  alarm.  It  is  very  apt  to 
recur,  sometimes  night  after  night ;  and  there  may  be  several  closely 
successive  attacks  in  one  night.  Sufferers  from  this  disorder  are  said 
by  their  mothers  to  be  "  subject  to  croup."  In  almost  every  case  some 
catarrhal  symptoms  can  be  established  by  the  careful  observer,  and  there 
is  often  a  considerable  degree  of  fever.  The  cough  is  loud  and  hoarse, 
unlike  the  whispering  cough  of  severe  obstructive  inflammation  of  the 
larynx ;  and  the  noisy  croujDy  breathing  is  almost  wholly  inspiratory, 
affording  thus  another  distinction  from  membranous  laryngitis.  The 
urgent  symptoms  soon  subside,  and  the  breathing  becomes  comparatively 
or  quite  quiet.  Examination  of  the  fauces  shows  either  nothing  ab- 
normal or,  more  frequently,  a  slight  redness  or  swelling  of  the  mucous 
membrane  with  some  tonsillar  enlargement,  or,  it  may  be,  ulceration. 
It  would  be  a  mistake,  however,  to  suppose  that  such  attacks  as  are  here 
described  never  indicate  any  more  serious  affection  of  the  air-passages ; 
for  a  child  predisposed  to  spasm  may  thus  suffer  at  the  outset  of  an 
ultimately  severe  laryngitis  or  even  of  diphtheria.  It  is  always  well  to 
wait  awhile  before  pronouncing  any  given  case  to  be  of  the  class  we 
are  describing,  and  before  giving,  in  consequence,  the  very  favourable 
prognosis  which  this  affection  per  se  usually  justifies.  We  should  also 
remember  that,  the  cause  of  this  disorder  being  catarrhal,  it  is  not 
uncommon  to  find  the  catarrh  spreading  to  the  bronchial  tubes  or  the 
lungs,  especially  in  its  younger  subjects ;  and  that  thus,  although  the 
incidental  spasmodic  phenomena  which  were  first  noticed  may  have  led 
to  a  hopeful  forecast,  the  case  may  soon  be  grave  or  fatal. 

As  regards  treatment,  all  cases  should  be  confined  to  bed  and  sur- 
rounded by  a  hot  moist  atmosphere,  if  possible  by  means  of  a  bed-tent  and 
steam-kettle.  A  hot  mustard  bath,  which  alone  may  promptly  relieve 
the  most  urgent  symptoms,  should  be  given  at  the  outset.  Counter-irrita- 
tion, in  the  form  of  a  mustard  poultice  to  the  upper  part  of  the  chest, 
is  strongly  advisable ;  and  warm  drinks  should  be  frequently  given.  An 
emetic  of  antimony  wine,  given  early,  seems  sometimes  to  be  of  use, 
possibly  as  diminishing  spasm ;  and  small  doses  of  this  drug  in  a  saline 
mixture  may  be  continued  every  three  or  four  hours.  If  our  diagnosis 
be  correct  that  the  case  is  not  one  of  membranous  laryngitis,  the  child 


344  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

will  in  all  probability  be  much  better  under  this  treatment  in  from 
twelve  to  twenty-four  hours. 

Prophylactic  treatment  is  very  important,  and  all  care,  therefore,  should 
be  taken  to  protect  from  cold  the  child  who  has  once  suffered.  With 
this  object  I  recommend  cool  or  cold  baths  daily,  and  thoroughly  warm 
clothing. 

Acute  Laryngitis. 

Under  this  heading  I  shall  consider  the  various  grades  of  inflammatory 
affections  of  the  larynx,  whether  of  simply  catarrhal  or  of  membranous 
nature.  Laryngitis  is  characterised  by  alteration  of  the  voice  and  by 
cough,  and,  in  its  severer  forms,  by  interference  with  the  breathing, 
often  amounting  to  serious  obstruction.  Usually  it  is  accompanied  by 
tracheitis  and  more  or  less  bronchitis;  the  membranous  form  being 
especially  marked  by  a  tendency  to  extensive  involvement  of  the  bron- 
chial tree. 

It  is  usual  to  class  acute  laryngitis  in  children  as  "simple"  and 
"  membranous."  During  life,  however,  it  is  more  by  inference  from  the 
results  of  previous  experience  than  by  direct  observation  that  we  make 
the  diagnosis  between  these  forms  ;  for,  with  the  exception  of  the  com- 
paratively few  cases  where  membranous  casts  may  be  coughed  up  spon- 
taneously or  after  the  action  of  an  emetic,  the  existence  of  membrane 
can  be  established  only  by  tracheotomy  or  by  post-mortem  examination. 
Further,  the  question  of  the  diphtheritic  nature  of  cases  which  we  either 
suspect  or  have  proved  to  be  membranous  adds  another  problem  to  the 
diagnosis.  In  the  matter  of  acute  laryngitis,  then,  we  have  clinically,  at 
one  pole,  the  simple  or  catarrhal  cases  with  many  degrees  of  symptomatic 
gravity,  as  best  typified  by  the  examples  met  with  in  the  early  stage 
of  measles;  and,  at  the  other,  the  confessedly  diphtheritic  laryngitis, 
as  evidenced  by  the  presence  of  faucial  or  nasal  membrane  and  other 
symptoms  of  diphtheria.  Between  these  two  extremes  there  is  an 
serologically  questionable  class  of  cases,  which  are  characterised  during 
life  and  also  after  death  by  membrane  in  the  air-passages1  alone,  and  are 
unmarked  by  any  other  symptom  or  sign  of  the  universally  recognised 
diphtheria. 

The  term  catarrhal  laryngitis  denotes  such  cases  as  are  directly  due 
to  catarrh  of  the  laryngeal  structures,  are  usually  associated  with  signs  of 
catarrh  elsewhere,  generally  recover,  and  are,  even  when  fatal,  unmarked 
by  membranous  exudation  in  the  air-passages.  Of  this  the  best  example 
is  seen  in  measles  before  the  rash  appears.  The  symptoms  are  loud 
brassy  cough,  hoarse  voice,  rasping  inspiration,  and  more  or  less  dyspnoea 
which  is  markedly  increased  during  sleep  and  when  agitation  induces 
crying.     At  this  stage  the  affection  may  remain,  and  may  soon  disappear, 


LARYNGEAL  AND  LARYNGO-TRACHEAL  AFFECTIONS.       345 

with  its  accompanying  fever,  under  the  treatment  referred  to  in  the 
preceding  section,  or  sometimes  without  any  treatment  at  all.  Other 
cases  are  aggravated  by  great  dyspnoea  with  stridor,  sometimes  of  an 
expiratory  character,  and  marked  by  the  working  of  the  accessory  muscles 
of  respiration  and  even  by  recession  of  the  soft  parts  of  the  thorax. 
For  a  time  it  is  impossible  to  differentiate  these  cases  clinically  from 
those  with  membranous  exudation,  whether  diphtheritic  or  not ;  and 
those  who  recognise  a  membranous  laryngitis  apart  from  the  results  of 
the  diphtheritic  poison  must  probably  admit  that  a  catarrhal  inflamma- 
tion may  become  membranous.  It  is  mainly  in  the  milder  cases,  with 
clear  evidence  of  general  catarrh,  that  the  diagnosis  of  simple  catarrhal 
laryngitis  can  be  made  with  a  fair  amount  of  confidence ;  but  in  all 
severe  cases,  beginning  suddenly,  even  where  there  is  marked  expiratory 
stridor,  we  must  wait  until  the  fifth  day  for  the  possible  appearance  of 
the  measles  rash  before  we  diagnose  a  membranous  laryngitis.  In  con- 
nexion with  catarrhal  laryngitis  we  must  remember  some  cases  which 
are  due  to  traumatism,  such  as  the  inhalation  of  irritant  vapours  or  of 
steam  from  attempting  to  drink  from  a  kettle-spout,  the  severer  examples 
of  which  are  not  seldom  marked  by  a  membranous  exudation  in  the 
upper  air-passages;  and  also,  possibly,  some  instances  of  membranous 
tracheitis  which  are  apparently  the  result  of  irritation  by  a  trache- 
otomy tube  in  cases  with  no  previous  evidence  of  the  existence  of 
membrane. 

In  the  absence  of  evidence  of  membrane,  of  signs  of  diphtheria  in 
the  nose  or  fauces,  or  of  other  symptoms  of  that  disease,  and  of  any 
history  of  concomitant  cases  or  of  marked  epidemic  prevalence,  the 
provisional  diagnosis  of  catarrhal  laryngitis  may  be  made.  The  child 
should  be  placed  in  a  bed  surrounded  by  a  steam-tent ;  a  small  mustard 
leaf  should  be  applied  over  the  sternal  notch  and  followed  by  continuous 
hot  fomentations ;  and  repeated  small  doses  of  antimony  wine  may  be 
given  in  a  saline  mixture.  In  cases  where  the  dyspnoea  is  great,  vomiting 
should,  if  possible,  be  produced  by  emetic  doses  of  antimony  wine  or  of 
the  sulphate  of  zinc  or  copper.  Failing  these,  -gj  to  ^  of  a  grain  of 
apomorphia  may  be  subcutaneously  injected.  Under  this  kind  of  treat- 
ment most  cases  of  catarrhal  laryngitis  Avill  recover  or  at  any  rate 
improve ;  but  if  the  affection  be  membranous  there  will  be  no  improve- 
ment, or  at  most  but  very  temporary.  When  the  pulse  intermits  with 
each  inspiration,  when  the  retraction  of  the  soft  parts  of  the  thorax 
continues,  when  hardly  any  air  enters  the  bases  of  the  lungs,  and  when 
the  child  is  becoming  droAvsy  and  apathetic,  operation  is  demanded ;  and 
in  the  immense  majority  of  cases  membrane  is  thereby  revealed.  "  Scores 
of  times,"  says  Mr.  Scott  Battams,  with  his  very  extensive  experience 
during  many  years  at  the  East  London  Hospital  for  Children.  "I  have 


346  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

had  to  face  this  problem  and  my  decision  to  operate  has  nearly  always 
been  followed  by  the  discovery  of  membrane." 

It  will  be  seen  here  that  we  encounter  at  this  point  some  difficulty 
both  as  to  diagnosis  and  treatment — a  difficulty  presently  to  be  dealt 
with  in  connexion  with  membranous  laryngitis  ;  but  the  practical  lesson 
of  cautious  and  expectant  treatment  at  any  rate  is  to  be  learned  from 
the  greatly  probable  recovery  of  cases  of  catarrhal  laryngitis,  however 
severe,  at  the  onset  of  measles,  which  so  frequently  suggest  tracheotomy 
to  the  inexperienced ;  and  from  the  fact  that,  however  treated,  by  trache- 
otomy or  otherwise,  cases  of  non-traumatic  membranous  laryngitis  under 
two  years  old  are  extremely  often  fatal. 

The  term  "membranous  laryngitis,"  or  its  often-used  equivalent 
"true  croup,"  denotes,  from  the  clinical  point  of  view,  cases  of  severe 
and  dangerous  laryngeal  dyspnoea  with  frequent  involvement  of  the 
lower  air-passages,  evidenced  by  physical  signs  during  life ;  and  marked 
post-mortem  by  false  membrane  in  the  larynx  or  trachea  or  both,  and 
very  often  by  a  continuation  of  the  exudation  in  the  bronchial  ramifica- 
tions. The  false  membrane  consists  of  fibrin,  pus,  and  dead  epithelium  ; 
and  becomes  less  tenacious  and  adherent  to  the  underlying  tissues,  the 
lower  it  extends. 

The  causes  of  universally  acknowledged  membranous  laryngitis  are 
the  diphtheritic  poison  and  traumatism ;  and  many  believe  that  there  is 
a  more  or  less  extensive  class  of  cases  which  is  unconnected  with  these 
agencies  and  probably  due  to  a  severe  degree  of  simple  inflammation. 
There  is,  however,  a  very  wide-spread  belief  at  present  among  patho- 
logists, clinicians,  and  systematic  writers  generally  who  love  finality, 
(with  the  notable  exception  of  several  who  have  had  prolonged  experience 
of  disease  in  childhood)  that,  apart  from  occasional  cases  of  traumatism, 
membranous  exudation  in  the  air-passages  is  always  diphtheritic  in 
origin.  This  almost  threadbare  question  is  still  unsolved,  and  will 
probably  remain  so  until  we  are  able  positively  to  test  the  diphtheritic 
process  by  an  absolute  histological  or  bacteriological  criterion,  and,  still 
more,  to  apply  such  criterion  to  cases  where  membranous  exudation  is 
confined  to  the  air-passages.  As  yet,  in  spite  of  the  strongest  pro- 
bability of  diphtheria  being  due  to  the  action  of  the  Klebs-Lceffier 
bacillus,  we  have  mainly  to  trust  to  other  clinical  observations,  and  to 
post-mortem  phenomena,  as  the  basis  of  our  opinion  on  the  question 
of  the  universally  diphtheritic  origin  of  membranous  laryngitis ;  and  it 
would  appear  that,  thus  far,  the  presence  of  the  specific  bacillus  has 
not  been  by  any  means  established  in  all  cases  of  either  membranous 
pharyngitis  or  membranous  laryngitis  in  which  it  has  been  searched  for. 
Baginsky  especially  has  stated 1  that  there  are  two  forms  of  tonsillar 
1  See  Archiv.  fur  Kinderheilkunde,  Bd.  XIII. 


LARYNGEAL  AND  LARYNGOTRACHEAL  AFFECTIONS.       347 

and.  pharyngeal  disease,  marked  by  membrane,  which  are  clinically  indis- 
tinguishable except  by  the  presence  or  absence  of  this  bacillus  as  estab- 
lished by  cultures ;  and  that  the  one  form  is  true  diphtheria  and  highly 
fatal,  while  the  other  is  not  dangerous  to  life.  It  must,  however,  be 
freely  conceded  that  cases  of  membranous  exudation,  strictly  confined 
to  the  air-passages,  as  evidenced  by  post-mortem  examination,  may  occur 
in  such  close  connexion  with  cases  of  confessed  diphtheria  as  practically 
to  remove  all  doubt  of  their  diphtheritic  origin,  and  that  they  may  pro- 
bably give  rise  by  infection  to  the  ordinary  faucial  disease ;  and,  conse- 
quently, that  in  many  individual  cases  of  membranous  laryngitis  it  may 
be  impossible  to  deny  their  diphtheritic  nature,  either  in  life  or,  some- 
times, even  after  death.  But  in  my  opinion  the  fact  remains  that  there  is 
a  very  considerable  number  of  cases  of  membranous  laryngitis  in  children, 
which,  in  their  whole  course  to  recovery,  with  or  without  tracheotomy, 
or  to  death,  have  no  sign  in  common  with  recognised  diphtheria  other 
than  the  presence  of  membranous  exudation.  As  long,  then,  as  membrane 
alone  is  not  explicitly  regarded  as  sufficient  evidence  of  the  working  of  the 
diphtheritic  poison,  this  clinical  question  awaits  further  solution ;  and  it 
is  perhaps  now  of  greater  importance  than  ever  since  the  official  recogni- 
tion of  diphtheria  as  an  infectious  disease  by  the  Local  Government  Board, 
and  the  consequently  possible  treatment  side  by  side  Avith  diphtheria  of 
cases  of  membranous  laryngitis,  which  so  many  consider,  in  my  opinion 
erroneously,  as  ipso  facto  diphtheritic.  I  add  briefly  the  following 
reasons  which  seem  to  me  to  oppose  the  doctrine  of  the  necessary  unity 
of  diphtheria  and  membranous  laryngitis.  First,  a  very  considerable 
number  of  cases  of  membranous  laryngitis  are  sporadic,  and  neither  in 
life  nor  after  death  show  any  sign  of  the  faucial  or  nasal  involvement 
which  is  an  integral  element  in  the  original  conception  of  diphtheria. 
This  fact  is  established  by  many  cases  in  my  experience,  both  clinically 
and  by  post-mortem  evidence ;  and  I  state  this,  fully  recognising  that 
false  membrane  which  has  escaped  observation  during  life  is  frequently 
found  after  death  in  the  upper  part  of  the  pharynx.  Second,  most  of 
the  severest  cases  of  membranous  laryngitis  have  laryngeal  symptoms 
from  the  outset  of  their  illness,  and  can  but  seldom  be  regarded  as 
instances  of  extension  from  the  pharynx  ;  a  small  minority  only  of  cases 
admitted  to  hospital  as  evident  faucial  diphtheria  showing  subsequently 
very  marked  laryngeal  symptoms.  My  own  experience  negatives  the 
prevalent  dictum  that  there  is  a  very  frequent  tendency  for  the  faucial 
diphtheritic  process  to  spread  after  many  days  to  the  air-passages. 
Confessedly  diphtheritic  laryngitis  as  a  rule,  though  not  always,  sets  in 
early  in  the  course  of  the  pharyngeal  affection.  Third,  the  cases  where 
the  symptoms  and  signs  are  limited  entirely  to  the  respiratory  tract  are 
mainly  sporadic;  epidemic  diphtheria  numbering  but  few  purely  laryngeal 


348  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

cases.  Further,  they  very  rarely  infect  others.  In  all  the  many  cases  of 
direct  infection  I  have  known  there  has  been  a  marked  membranous 
appearance  in  the  fauces  or  nose.  Albuminuria,  too,  is  seldom  present, 
and  then  only  in  a  slight  degree,  in  purely  laryngeal  cases.  Fourth,  the 
frequent  occurrence  of  membranous  laryngitis  after  measles,  without  any 
other  sign  or  probable  source  of  diphtheritic  infection,  favours  the  view 
of  its  non-specific  nature  in  many  instances.  It  must  be  held  by  those 
who  regard  membrane  anywhere  as  always  of  diphtheritic  nature  that 
measles  establishes  a  special  proclivity  to  diphtheria ;  but,  if  this  be  so, 
the  proportion  of  cases  of  measles  marked  by  a  pharyngeal  membranous 
deposit  would  surely  be  considerable.     It  is,  in  truth,  but  very  small. 

I  have  already  said  that  the  early  diagnosis  between  diphtheritic  and 
non-diphtheritic  membranous  laryngitis  is  not  always  possible.  In  the 
absence  of  further  evidence  of  diphtheria  we  are  largely  influenced  by 
the  matter  of  epidemic  prevalence.  The  sequent  paralysis  of  diphtheria 
is  too  late  to  be  of  diagnostic  value  ;  and  the  old  argument  of  the  asthenic 
type  of  diphtheria  and  the  sthenic  type  of  croup  is  of  little  practical 
use.  With  regard  to  the  treatment  of  individual  cases  this  diagnostic 
difficulty  is  not  very  important;  but  I  believe  that,  in  face  of  present 
evidence,  we  are  not  justified  in  grouping  or  treating  together  all  cases 
of  membranous  laryngitis.  We  should,  when  possible,  isolate  the  sick 
from  the  healthy,  but  never  subject  them  to  the  contagion  of  confessed 
diphtheria  while  doubt  as  to  the  nature  of  the  case  remains. 

In  membranous  laryngitis  we  find  the  symptoms  of  laryngeal  obstruc- 
tion in  accentuated  form.  Besides  the  hoarseness  of  voice  and  cough, 
and  the  noisy  respiration,  the  expiration  is  markedly  strident ;  and  great 
difficulty  of  breathing  is  shown  by  the  actively  dilating  nostrils,  the 
backward  movement  of  the  head,  and  the  inspiratory  retraction  of  the 
soft  parts  of  the  thorax  and  the  lower  ribs.  This  condition  is  emphasised 
by  sleep.  As  the  affection  progresses  the  head  is  persistently  thrown 
back  ;  the  face  becomes  cyanotic ;  the  expression  anxious ;  the  voice 
whispering ;  the  pulse  feeble,  and  intermittent  with  inspiration  ;  the 
cough  silent;  and  the  child  often  clutches  at  its  throat.  The  respiratory 
frequency  is  not  very  great  until  there  is  considerable  involvement  of 
the  bronchial  tubes ;  nor  is  the  temperature  generally  high,  though  there 
is  always  some  fever.  The  prevalent  restlessness  greatly  hurries  the 
pulse-rate. 

It  is  the  severity  and  ingravescence  of  these  symptoms  that  point  to 
the  diagnosis  of  the  case  as  one  of  membranous  laryngitis,  especially 
when  the  probability  of  early  measles  and  of  "  oedema  glottidis  "  can  be 
excluded.  Although  this  condition  may  be  met  with  in  a  marked 
degree  in  purely  catarrhal  cases,  we  know  as  a  fact  that  it  is  usually  asso- 
ciated with  membrane.     If  evidence  of  diphtheria  be  given  by  faucial 


LARYNGEAL  AND  LARYNGOTRACHEAL  AFFECTIONS.       349 

membrane,  great  nasal  obstruction,  markedly  enlarged  glands  at  the 
angle  of  the  jaw,  or  albuminuria,  the  diagnosis  of  membranous  laryngitis 
is  practically  certain;  and,  even  without  such  symptoms,  it  is  at  least 
probable  in  times  of  epidemic  diphtheria.  Very  sudden  development 
of  symptoms  of  laryngeal  obstruction  is  not  specially  indicative  of  the 
membranous  affection,  which  is  often  ushered  in  for  a  day  or  two  by  the 
milder  signs  of  laryngeal  and  often  bronchial  catarrh,  and,  in  confessedly 
diphtheritic  cases,  by  a  short  period  of  constitutional  disturbance  with 
some  fever.  Expulsion  of  the  membrane  by  coughing  is  a  definite  sign 
but  rarely  met  with.  I  have  already  said  that  the  diagnosis  of  mem- 
branous laryngitis  is  of  greater  practical  moment,  from  the  therapeutical 
point  of  view,  than  the  decision  as  to  whether  any  given  case  be  diph- 
theritic; and  would  add  that,  when  we  are  in  doubt  on  the  latter 
point,  as  we  so  often  are,  we  should  provisionally  diagnose  diphtheria. 
Undoubted  diphtheritic  involvement  of  the  fauces  is  occasionally  ob- 
served subsequently  to  symptoms  of  a  laryngitis  which  would  not  other- 
wise have  suggested  diphtheria.  It  is,  however,  in  my  opinion  certain,  as 
has  been  ably  insisted  on  by  Fagge,  and,  moreover,  recently  evidenced  by 
the  bacteriological  observations  of  Baginsky  above-mentioned,  that  not 
all  membranous-looking  exudations  on  the  tonsils,  in  cases  of  severe 
laryngitis  which  may  prove  to  be  membranous,  are  evidence  of  diph- 
theria. Pharyngitis  in  various  degrees  is  frequent  in  clearly  catarrhal 
cases  of  laryngitis ;  and  we  have  already  seen  that,  without  laryngitis, 
extensive  exudation  limited  to  the  tonsils  and  erroneously  styled  diph- 
theria by  many,  is  exceedingly  common.  One  point,  bearing  on  the 
diagnosis  of  membranous  laryngitis,  I  would,  from  frequent  observation, 
regard  as  of  some  practical  value.  In  cases  of  established  laryngitis 
where  inspection  shows  the  pharynx  to  be  quite  free  from  morbid 
appearances,  membrane  is  more  likely  to  be  present  than  when  the 
pharynx  is  red  and  swollen,  and  covered  with  dirty  mucus. 

When  the  probability  of  membranous  laryngitis  has  been  established, 
the  prognosis  is  always  grave.  Under  the  age  of  two  years  an  immense 
majority  of  cases  die,  however  they  may  be  treated.  Without  treatment, 
the  obstruction  in  the  larynx  and  trachea  may  be  soon  fatal ;  the  mem- 
brane rapidly  increasing  although  some  of  it  may  be  artificially  or,  some- 
times, naturally  expelled.  The  frequent  extension  of  the  exudation  to 
the  smaller  bronchi  and  bronchioles,  causing  signs  of  bronchitis  and 
broncho-pneumonia  which  are  evidenced  post-mortem,  is  a  still  more 
frequent  cause  of  death,  and  too  often  frustrates  the  relief  attained  by 
intubation  or  tracheotomy.  Increased  pyrexia  and  frequency  of  breath- 
ing are  the  best  clinical  evidences  of  this  extension,  when  auscultation 
may  fail  us  owing  to  the  predominance  of  the  laryngeal  sounds  over  the 
rales  and  rhonchi  of  the  smaller  tubes.     In  these  cases  the  child  sinks 


3  50  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

into  somnolence  and  coma,  the  strident  sounds  subside,  and  death  is 
often  preceded  by  convulsive  twitchings. 

The  treatment  of  cases  of  supposed  or  demonstrable  membranous 
laryngitis,  as  of  those  of  acute  laryngitis  generally,  must  be  promptly 
undertaken.  If  hot  mustard  baths,  counter-irritation  to  the  laryngo- 
tracheal region,  or  the  abstraction  of  blood  therefrom  by  means  of 
leeches  fail,  and  emetics  be  inoperative,  all  depressant  remedies  should 
be  avoided;  for  the  child  needs  all  its  strength  for  the  chance  of 
recovery.  A  steam-tent  is  advisable  from  the  first,  nourishment  should 
be  frequently  given,  and  alcoholic  stimulation  is  almost  always  indi- 
cated. "With  persistence  or  increase  of  symptoms  of  obstruction,  and 
especially  if  there  be  marked  inspiratory  intermittence  of  pulse  and 
recession  of  the  soft  parts  of  the  thorax,  operative  interference  should 
not  be  long  delayed.  There  is  in  my  opinion  but  little  reason  to  believe, 
as  Henoch  does,  that  the  simply  inflammatory  membranous  cases  give 
greater  hope  for  recovery  under  operative  treatment  than  the  confessedly 
diphtheritic ;  for  although,  as  he  insists,  the  tendency  to  death  in  diph- 
theria is  multiform,  while  in  simple  "  croup "  it  is  the  local  affection 
which  kills,  my  experience  of  the  great  mortality  of  all  cases  forbids  me 
to  adduce  such  an  argument  in  support  of  my  belief  in  the  non-identity 
of  croup  and  diphtheria.  The  immediate  prognosis  of  membranous 
laryngitis,  from  whatever  cause  arising,  must  depend  mainly  on  the 
severity  and  rapidity  of  ingravescence  in  each  individual  case.  When 
there  is  evidence  of  involvement  of  the  lungs,  there  is  but  little  hope 
of  ultimate  success  from  the  artificial  admission  of  air.  The  effect  of 
intubation  or  tracheotomy  being  mainly  or  only  the  entry  of  air  into 
the  lungs,  the  steam-tent  and  general  treatment  must  be  persevered  with 
after  the  operation.  In  spite  of  much  doubt  and  even  opposition  on  the 
part  of  several  authorities  as  to  the  efficacy  of  hot  moist  atmosphere, 
I  am  well  convinced  that  it  is  necessary  for  the  best  chance  of  success. 
Of  the  relative  merits  of  tracheotomy  and  intubation  in  acute  mem- 
branous laryngitis,  as  well  as  of  local  after-treatment  and  sundry 
complications,  I  shall  say  but  little,  leaving  these  important  details  to 
the  province  of  the  surgeon.  Intubation  may  be  tried  at  first  in  cases 
requiring  operative  aid,  and  often  gives  complete  relief  to  the  laryngeal 
obstruction.  Tracheotomy  instruments  should,  however,  be  at  hand  (as 
insisted  on  by  Dr.  Hastings,  from  his  extensive  experience  at  Shadwell, 
and  by  others),  owing  to  the  risk  of  the  membrane  being  pushed  down 
by  the  intubation  tube  and  thus  blocking  the  trachea ;  and,  as  there 
is  some  danger,  at  least  with  many  tubes,  that  ulceration  may  be  rapidly 
set  up  by  irritation,  the  tube  should  not  be  allowed  to  remain  for  more 
than  twenty-four  hours  without  removal.  There  is  occasionally  some 
difficulty    in    its    re-introduction.       In    very    bad    cases,   with    marked 


LARYNGEAL  AND  LARYNGOTRACHEAL  AFFECTIONS.        3  5  I 

expiratory  stridor,  tracheotomy  on  the  whole  is  indicated  in  preference 
to  intubation ;  and  it  must  be  said  on  behalf  of  tracheotomy  that  the 
after-treatment  is  thereby  better  carried  out.  Evidence  of  diphtheritic 
disease  of  the  fauces  or  nose  contra-indicates  intubation ;  for  only  by 
tracheotomy  can  the  inspired  air  be  prevented  passing  over  the  infected 
surfaces. 

It  is  on  the  whole  very  unlikely  that  intubation  will  supersede  trache- 
otomy (at  least  in  England,  where  neither  operation  is  lightly  undertaken 
in  cases  which  experience  shows  will  probably  recover  if  left  alone), 
owing  both  to  its  frequent  failure  in  really  acute  cases  and  to  the  much 
greater  expense  and  difficulty  of  management  of  the  instruments.  I 
would  further  observe  that  the  great  objection  often  made  to  tracheotomy, 
on  the  ground  of  the  frequently  sequent  broncho-pneumonia  found  in 
fatal  cases,  is  practically  almost  baseless ;  for  this  morbid  phenomenon 
is  really  the  result  of  the  extending  disease.  Erom  many  post-mortems 
that  I  have  seen  I  feel  sure  that  there  is  no  material  difference  in  this 
particular  between  the  cases  which  have  died,  whether  or  no  they  have 
been  tracheotomised. 

Chronic  Laryngeal  Disease. 

There  is  but  little  special  to  childhood  to  be  dwelt  on  under  this 
heading.  Chronically  altered  or  absent  voice  and  greater  or  less  impedi- 
ment to  breathing  may  be  due  to  papillomatous  or,  sometimes,  other 
tumours,  both  benign  and  (though  very  occasionally)  malignant ;  to 
syphilitic  ulceration  in  the  larynx ;  or  to  tubercle.  Sometimes,  after  a 
long  course  of  laryngeal  symptoms  with  recurrent  exacerbations,  trache- 
otomy, necessitated  by  an  exceptionally  bad  attack,  may  reveal  the  pre- 
sence of  membrane.  I  have  seen  two  instances  of  this  where  there 
was  no  other  evidence  of  diphtheria.  It  is  probable  that  the  mem- 
branous inflammation  here  was  an  instance  of  acute  disease  arising  out 
of  chronic,  though  some  may  maintain  that  the  diphtheritic  poison  was 
at  work  on  the  tissues  already  made  susceptible  by  the  chronic  lesion. 
Simple  chronic  laryngeal  catarrh  in  childhood,  arising  from  the  acute 
form,  is  not  common.  It  occurs  mostly  in  ill-nourished  children,  and 
after  measles.  In  cases  which  recover  from  membranous  laryngitis, 
whether  diphtheritic  or  not,  laryngeal  trouble,  both  vocal  and  respiratory, 
may  persist,  even  after  it  is  possible  to  dispense  with  the  tracheotomy 
tube  which  may  have  been  worn.  But  in  most  of  such  cases  tracheotomy 
has  been  necessary,  and  is  probably  causal.  I  have  known  but  few 
instances  of  recovery  without  tracheotomy  where  the  breathing  and  voice 
have  not  been  soon  perfectly  restored. 

The  diagnosis  of  the  various  forms  of  chronic  laryngeal  disease  in 
childhood  rests  mainly  on  inference  from  the  history  of  the  case  and 


3  5  2  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

on  concomitant  signs  and  symptoms.  Laryngoscopic  examination,  when 
possible,  is  very  important.  Warty  growths,  especially  when  occurring 
in  a  child  with  a  marked  history  of  syphilis,  may  be  overlooked  when 
laryngoscopy  is  impracticable,  as  in  a  case  of  my  own  which  was  ulti- 
mately tracheotomised.  In  another  case  of  long  standing,  where  the 
history  pointed  to  a  quite  sudden  onset  of  the  laryngeal  symptoms, 
the  diagnosis  was  chronic  pharyngo-laryngitis,  the  tonsils  and  pharynx 
being  much  swollen.  Laryngoscopy  was  several  times  unsuccessfully 
attempted.  Tracheotomy,  necessitated  by  an  exacerbation  of  symptoms 
during  an  attack  of  broncho-pneumonia,  relieved  the  breathing;  but  when, 
several  months  afterwards,  the  child  died  from  broncho-pneumonia  with 
measles,  still  wearing  her  tracheotomy  tube,  abundant  warty  growths 
were  found  on  the  cords  and  elsewhere  in  the  larynx. 

Suspected  syphilitic  cases  are  best  treated  with  iodide  of  potassium  or 
a  combination  of  that  salt  with  the  bichloride  of  mercury.  I  never  trust 
to  mercury  alone  in  any  syphilitic  condition  calling  for  prompt  treatment. 
In  all  instances  local  treatment  of  the  interior  of  the  larynx  should  be 
tried,  such  as  the  application  of  the  strong  solution  of  perchloride  of  iron 
with  glycerine,  of  the  strength  of  one  drachm  to  the  ounce,  once  or  twice 
a  week.  In  cases  due  to  catarrh  this  method  is  frequently  satisfactory. 
Every  attention  should  be  given  to  ensure  good  nutrition,  healthy  sur- 
roundings, and  avoidance  of  chills.  Chronic  affections  requiring  operative 
treatment  have  no  special  mark  in  childhood. 


CHAPTER  III. 

TRACHEOBRONCHIAL  CATARRH  AND  CHRONIC  BRONCHITIS. 

Catarrh  limited  to,  or  at  least  mainly  affecting,  the  trachea  and 
primary  bronchi,  without  prominent  laryngeal  symptoms,  although 
often  accompanied  by  slight  hoarseness,  is  common  after  infancy ;  but  is 
not  very  frequently  met  with  in  the  first  few  years  of  life.  We  have 
seen  that  such  a  catarrh  often  immediately  precedes  a  laryngeal  attack ; 
and  the  consideration  of  general  bronchitis  and  broncho-pneumonia 
teaches  us  how  great  is  the  tendency  for  catarrh  of  any  part  of  the 
respiratory  tract  to  involve  the  smaller  bronchi  and  air-cells  in  infancy. 
It  is  mainly  in  children  over  four  years  old  that  we  meet  with  the 
ordinary  and  generally  unimportant  "cold  in  the  chest,"  with  which  we 
are  all  familiar,  marked  by  pain  behind  the  upper  part  of  the  ster- 
num, hard  painful  cough,  some  hoarseness,  and,  at  first,  by  scanty  or  no 


TRACHEOBRONCHIAL  CATARRH.  353 

expectoration.  The  attack  is  attended  by  little  or  no  fever.  Doubtless 
in  many  or,  perhaps,  most  cases  of  infantile  pulmonary  catarrh  such  a 
comparatively  limited  condition  exists  for  a  short  time;  and  there  is,  in 
addition  to  this,  a  practical  reason  for  shortly  considering  these  cases  as 
a  separate  clinical  group.  Early  treatment  by  warmth  and  confinement 
to  bed,  aided  by  vigorous  local  counter-irritation  applied  to  the  upper 
sternal  region  and  the  administration  of  the  compound  powder  of 
ipecacuanha,  will  very  frequently  be  followed  by  arrest  of  the  catarrhal 
process,  and  probably  prevent  the  involvement  of  the  small  bronchi  and 
air-cells.  The  earliest  symptoms,  then,  of  a  "  cold  in  the  chest "  in  a 
young  child,  however  slight,  should  never  be  neglected ;  for  in  any  such 
case  there  may  be  a  potential  laryngitis  or  broncho-pneumonia.  In  older 
patients  we  observe  the  greater  frequency  of  the  well-known  tracheo- 
bronchial catarrh,  which  usually  runs  its  course  to  recovery  in  a  few 
days  or  weeks  according  to  the  care  or  neglect  which  may  be  bestowed 
upon  it. 

The  physical  signs  of  this  affection  are,  at  the  most,  coarse  rhonchus, 
generated  in  the  larger  bronchi  and  alterable  by  cough,  and  some 
lengthening  and  harshening  of  the  expiratory  sound.  In  many  cases 
there  may  be  no  auscultatory  signs.  The  cough,  however,  may  be  very 
loud,  frequent  and  troublesome ;  and  there  may  be  some  sense  of  oppres- 
sion in  breathing.  Expectoration  is  very  rarely  observed  in  children  under 
five  or  six,  and  but  seldom  in  those  under  ten,  years  of  age. 

This  condition  is  frequently  seen  in  an  extended  form  in  whooping- 
cough,  and  not  seldom  in  measles ;  and  may  pass  into  chronic  bronchitis. 
"When  the  rhonchi  are  abundant,  accompanied  by  sibili  signifying  the 
involvement  of  smaller  tubes,  and,  still  more,  by  moist  rales,  the  case 
becomes  one  of  general  bronchitis  presently  to  be  considered  in  close 
connexion  with  broncho-pneumonia.  I  would  repeat  that  acute  bron- 
chial catarrh  limited  to  the  larger  tubes  is  mainly  seen  beyond  infancy  : 
while  primary  acute  general  bronchitis  pre-eminently  affects  infants  and 
quite  young  children.  After  this  early  age  acute  general  bronchitis  is 
most  often  a  secondary  affection,  and  should  always  suggest  the  pre- 
existence  of  other  morbid  conditions.  Of  these,  among  others,  heart 
disease,  kidney  disease,  tuberculosis,  and  the  zymotic  disorders  (especially 
whooping-cough,  influenza,  measles  and  enteric  fever)  should  be  thought 
of,  as  well  as  chronic  bronchitis,  out  of  which  an  acute  attack  so  often 
arises. 

Chronic  Bronchitis. 

This  affection,  frequently  seen  in  quite  early  childhood,  is  in  my 
opinion  fittingly  considered  here,  from  the  clinical  point  of  view,  before 
the  acute  form  of  the  disease ;  for  their  relationship  is  far  more  often 
that  of  acute  upon  chronic  than  chronic  upon  acute ;  and,  when  chronic 

Z 


3  54  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

bronchitis  does  seemingly  arise  out  of  repeated  attacks  of  acute  or  sub-acute 
bronchial  catarrh,  these  attacks  are  usually  not  of  the  serious  form  known 
as  acute  general  bronchitis  with  more  or  less  fever,  but  rather  of  the  non- 
febrile  kind  previously  dealt  with,  the  smaller  tubes  not  being  involved. 

Chronic  bronchitis  in  childhood,  from  whatever  cause  arising,  generally 
begins  insidiously,  and  often  fails  to  attract  much  attention  until  it  has 
lasted  some  months.  Many  of  its  subjects  appear  perfectly  well,  their 
only  symptoms  being  cough  and  some  amount  of  wheezing.  The  cough 
is  paroxysmal,  worse  in  the  morning  and  evening,  and  rarely  accom- 
panied by  expectoration  until  after  the  age  of  five  years  or  later,  when  it 
may  be  very  abundant  and  sometimes  offensive.  I  have,  however,  more 
than  once  seen  copious  muco-purulent  sputum  in  children  of  three  years 
old.  Physical  examination  reveals  coarse  dry  rhonchi  and  moist  rales, 
and  sometimes  fine  rales  at  the  bases  of  the  lungs  behind.  The  per- 
cussion note  is  normal,  except  in  that  class  of  cases  marked  by  very  early 
emphysema.  In  these  severe  forms  dyspnoea  is  prominent,  the  child  is 
lethargic,  the  face  is  pale  or  bluish,  the  body  wastes  more  or  less,  the 
fingers  and  toes  may  become  bulbous,  and  the  sides  and  lower  part  of  the 
chest  may  be  drawn  in  with  inspiration.  The  inspiratory  murmur  is 
short  and  obscured,  the  emphysematous  sign  of  a  resonant  percussion-note 
over  the  cardiac  area  and  down  the  sternum  is  frequently  present,  and 
epigastric  pulsation  and  fulness  of  veins  may  give  evidence  of  enlargement 
of  the  right  heart.  In  some  cases  bronchial  or  cavernous  breathing,  with 
or  without  gurgling  sounds,  points  to  dilatation  of  bronchi. 

Every  case  of  chronic  bronchitis  is  liable  to  acute  attacks  of  varying 
severity  and  frequency ;  and  in  young  children  such  attacks  may  be 
broncho-pneumonic  and  fatal.  A  very  large  number  of  cases  of  moderate 
or  subacute  bronchitis  in  children,  with  little  or  no  fever,  are  merely 
exacerbations  of  the  chronic  disease.  Weakly  or  strumous  children,  as 
very  many  of  these  are,  with  a  history  of  wheezing  more  or  less  all 
their  life,  are  subject  to  sudden  attacks  of  collapse  of  lung  which  may 
be  rapidly  fatal.  "Witness  the  following  case  among  others  which  I 
have  seen.  A  child,  whose  mother  was  bronchitic,  had  been  ailing  and 
wheezing  off  and  on  since  birth,  and  began  to  suffer  from  increased  cough 
and  trouble  in  breathing  a  few  days  before  admission.  There  was  coarse 
rhonchus  all  over  the  back  with  doubtfully  impaired  percussion-note  at 
the  right  base  and  the  left  inter-scapular  region.  For  nearly  twelve 
days  the  child  remained  in  the  same  condition,  breathing  noisily  and 
coughing,  but  not  appearing  much  distressed  ;  and  the  temperature  varied 
between  99°  and  101°.  On  the  twelfth  day  he  became  suddenly  worse, 
and  died  after  a  short  struggle ;  the  temperature  just  after  death  was 
found  to  be  106.50.  Nothing  was  found  post-mortem  besides  complete 
collapse  of  the  middle  lobe  of  the  right  lung  and  slight  signs  of  bronchial 


TRACHEOBRONCHIAL  CATARRH.  3  5  5 

catarrh.     I  have  seen  ■  several  instances  of  a  rapidly  rising  temperature 
just  before  death  in  cases  of  sudden  and  extensive  pulmonary  collapse. 

This  affection  is  almost  universally  worse  in  the  winter ;  and,  in  its 
slighter  forms,  the  symptoms  remit  altogether  in  the  warmer  weather. 
Some  few  cases,  however,  seem  to  be  but  little  if  at  all  modified  by 
seasonal  change.  The  course  and  prognosis  of  the  disease  are  largely 
affected  by  its  determining  conditions  and  the  constitution  of  its  subjects. 

A  considerable  number  of  cases  of  chronic  bronchitis  are  not  referable 
to  any  exciting  cause,  and  are  connected  with  hereditary  tendency.  Such 
have  frequently  early  developed  emphysema  and  a  history  of  parental 
asthma  and  bronchitis.  Even  in  this  class  there  is  a  good  hope  of 
recovery  with  increasing  years,  good  nutrition,  and  suitable  climatic 
treatment.  I  have  seen  many  instances  of  this  variety  of  the  affection, 
and  am  convinced  of  its  clinical  importance.  In  neurotic  subjects 
spasmodic  asthma  is  often  excited  by  this  condition.  It  is  in  this  class 
of  cases  that  we  not  seldom  see  the  symptoms  enduring  more  or  less 
throughout  the  year. 

Chronic  bronchitis  is  extensively  associated  with  rickets,  quite  apart 
from  the  thoracic  deformity  to  which  that  disease  often  gives  rise ;  and 
may  indeed,  with  other  pulmonary  affections,  be  regarded  as  often  part 
and  parcel  of  the  rickety  state.  It  springs  too  out  of  measles  and  very 
often  out  of  ivhooping-cough,  and  in  this  case  is  the  best  example  of 
chronic  disease  following  on  severely  acute  bronchial  catarrh.  It  may 
indeed  be  said  that  a  large  majority  of  cases  of  chronic  bronchitis,  at  all 
ages,  are  the  result  of  whooping-cough,  and  very  especially  those  rare 
instances  which  begin  in  youth  and  early  maturity ;  and  that  such  an 
origin  much  encourages  asthmatic  tendencies. 

The  scrofulous  habit  is  specially  marked  by  a  tendency  to  prolonged 
bronchial  catarrhs  which  notably  diminish  or  disappear  with  improve- 
ment of  the  general  condition.  I  cannot  deny  that  repeated  attacks  of 
simple  acute  catarrh  may  set  up  a  chronic  bronchitis  ;  but,  considering  the 
rapid  restoration  of  the  epithelial  structures,  especially  in  childhood,  and 
the  clinical  fact  that  the  signs  of  even  chronic  and  continuous  bronchitis 
of  several  years'  standing  may  completely  disappear,  I  should  not  be 
inclined  to  regard  this  a  priori  as  a  very  frequent  cause ;  and  I  am  sure 
that  a  large  majority  of  cases  of  chronic  bronchitis  in  childhood  are  not 
sequelae  of  simple  acute  attacks,  but  either  are  insidious  in  origin  and 
frequently  hereditary,  or  result  from  rickets,  scrofula,  or  one  of  the 
zymotic  diseases. 

Chronic  bronchitis  may  lead  in  time  to  collapse  of  parts  of  the  lung, 
especially  at  the  base,  emphysema,  and  more  or  less  dilatation  of  the 
bronchial  tubes,  which  often  contain  thick  pus.  All  degrees  of  the  usual 
post-mortem  appearances  in  the  tubes  may  be  seen ;  but  as  a  rule  they 


356  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

are  not  prominent  in  childhood ;  and  the  lesion  does  not  often  extend 
"beyond  congestion  of  the  mucous  membrane,  marked  thickening  and 
extension  to  the  deeper  structures  being  rarely  observed.  It  is  to  be 
especially  noted  that,  in  spite  of  the  large  bubbling  sounds  and  other 
cavernous  signs  which  may  have  been  present,  saccular  dilatation  of  the 
bronchi  is  scarcely  ever  observed  post-mortem  in  cases  of  simple  chronic 
bronchitis  in  children  dying  from  an  acute  attack  or  some  other  disease. 
The  occurrence  of  true  bronchiectasis,  with  localised  cavernous  signs,  is 
probably  limited  to  cases  where  there  is  either  some  chronic  disease  of 
the  lung  itself,  especially  of  the  fibroid  variety,  or  pleurisy,  or  both  these 
conditions.  In  long-continued  cases  there  will  be  found  post-mortem  an 
enlarged  right  heart  with  congested  kidneys  and  liver. 

The  prognosis  in  the  chronic  bronchitis  of  childhood  is  doubtless 
much  better  than  in  later  life,  the  frequent  subsidence  of  the  symptoms 
with  proper  treatment  pointing  to  the  recovery  of  the  injured  tissues. 
Some  cases  resist  all  treatment,  and  may  contract  tuberculosis ;  and  in 
others  recurrent  and  sometimes  extensive  pleurisy  is  observed.  The 
frequent  intercurrence  of  acute  attacks  darkens  prognosis. 

Foremost  in  importance  as  regards  treatment  are  climatic  conditions. 
If  possible,  the  child  should  be  sent  for  the  winter  and  early  spring  to  a 
place  where  the  climate  permits  it  to  be  much  out  of  doors.  It  may  be 
true  that  most  cases  do  best  where  the  air  is  prevalently  dry,  such  as  it 
is  in  Eoypt,  Algiers,  some  of  the  European  resorts  on  the  Mediterranean 
coast,  or  at  Bournemouth.  Others,  however,  improve  much  at  such  places 
as  Madeira,  Pau,  or  Torquay.  Sea-voyages  are  often  highly  beneficial. 
I  do  not  think  that  any  hard-and-fast  rule  can  be  laid  down  for  individual 
cases ;  and  the  frequent  presence  of  an  asthmatic  tendency  often  renders 
prominent  the  unknown  quantity  as  regards  treatment.  As  to  home 
resorts,  I  can  speak  well  of  Bournemouth,  Torquay  and  Aberystwyth,  as 
all  very  suitable  to  certain  cases;  but  the  more  distant  places  above- 
mentioned  are  in  many  respects  to  be  preferred.  Cases  which  cannot  be 
sent  away  from  home  must  be  kept  in  warm  and  well-ventilated  rooms, 
and  allowed  to  go  out  on  warm  and  dry  days  only  as  a  rule,  or,  with 
caution,  in  cold  weather  when  the  air  is  still. 

Nutrition  should  be  maintained  by  generous  diet ;  but  we  should  bear 
in  mind  the  frequent  digestive  weakness  and  gastric  congestion  which 
mark  chronic  bronchitis.  Cod-liver  oil  is  undoubtedly  of  great  value  in 
many  cases,  as  well  as  iron  and  arsenic.  As  to  remedial  measures, 
especially  when  there  is  evidence  of  much  bronchial  secretion,  opium  in 
small  doses  is  pre-eminently  useful,  as  also  may  be  such  drugs  as  the 
Peruvian  and  tolu  balsams,  benzoin,  copaiba,  cubebs,  or  terebene.  In 
other  cases,  where  the  cough  is  hard  and  there  is  but  little  secretion,  the 
carbonate  of  ammonia  should   be   given,  and  iodide  of   potassium  or 


KMl'HYSKMA  AND  ASTHMA.  357 

iintimonial  wine  are  of  good  service.  Inhalation  of  steam  alone,  or  of 
steam  medicated  by  tincture  of  iodine,  tincture  of  benzoin,  creasote  or 
oil  of  turpentine,  frequently  gives  much  relief,  and  should  always  be 
tried  in  the  severer  cases.  The  strength  of  all  these  remedies  may  vary 
from  half  a  drachm  or  a  drachm  to  the  pint  of  water,  according  to  the 
individual  case.  In  proportion  to  the  prevalence  of  asthmatic  symptoms, 
such  remedies  as  belladonna,  lobelia,  and  aether  may  be  used  with  frequent 
advantage.  Of  squills,  senega,  ipecacuanha,  and  the  much  be-praised 
strychnia  I  can  but  say  that  after  frequent  trials  I  have  found  them 
practically  valueless  in  this  affection. 


CHAPTER  IV. 

EMPHYSEMA  AND  ASTHMA. 

Emphysema  in  all  its  forms  may  occur  in  quite  early  childhood,  but 
is  not  often  symptomatically  prominent.  In  its  generalised  and  appa- 
rently primary  form,  the  tendency  to  which  at  least  is  probably  heredi- 
tary, this  affection  is  often  overlooked  until  some  extra  stress,  perhaps  in 
later  life,  reveals  respiratory  weakness.  The  observations  of  Jackson  of 
Boston  regarding  heredity  in  emphysema  are  quite  in  accord  with  my 
own  experience.  He  found  that  of  28  emphysematous  patients  18  had  em- 
physematous parents,  while  of  50  non-emphysematous  patients  the  parents 
of  only  three  were  emphysematous.  I  have  several  times  established  by 
physical  examination  the  existence  of  undoubted  emphysema  in  young 
children  who  have  not  been  the  subjects  of  any  prolonged  catarrh,  or  of 
whooping-cough  ;  and  in  many  of  these  I  have  ascertained  that  one  parent 
was  subject  to  asthmatic  attacks.  I  believe  that  there  is  sufficient  clini- 
cal evidence  to  support  the  view  that  some  vice  of  lung-structure,  leading 
to  loss  of  elasticity,  is  transmitted  from  parent  to  child ;  and  that  this 
condition  explains  more  cases  of  primary  and  permanent  emphysema  in 
children  than  the  theory  of  premature  attempts  at  breathing  during  the 
process  of  birth. 

The  subjects  of  this  affection  have,  generally,  more  or  less  distended 
chests,  a  pale  complexion,  oldish  look,  and  a  spare  or  even  wasted  frame ; 
and  an  undue  excess  of  elevation  over  expansion  of  the  thorax  is  observed 
during  inspiration,  which  is  marked  by  a  short  and  deficient  sound  on 
auscultation.  In  many  cases  the  heart's  dulness  is  lessened  or  absent, 
the  pulmonary  note  is  over-resonant  on  percussion,  and  there  is  epigastric 
pulsation.  The  secondary  form  of  emphysema,  usually  described  as 
"  vicarious,"  where  the  lesion  is  of  more  partial  distribution,  is  common 


358  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

in  childhood.  It  occurs  in  connection  with  obstruction  to  the  upper  air 
passages ;  with  disease  which  interferes  with  the  action  of  parts  of  the 
lungs,  such  as  inflammation,  consolidation  or  compression  from  any 
cause;  and  with  violent  expiratory  efforts,  often  repeated  with  closed 
glottis,  as  typically  exemplified  in  whooping-cough.  Such  emphysema 
is  also  observed  in  cases  of  chronic  pleurisy  where  adhesions  prevent  the 
retraction  of  the  lung,  and  is  often  associated  with  dilatation  of  bronchi. 
In  cases  where  there  is  no  hereditary  predisposition  this  secondary  form 
of  dilatation  of  the  air  cells  may  disappear,  when  its  cause  is  removed, 
almost  as  readily  as  it  came ;  and  the  affection  is,  in  many  instances,  of 
no  great  importance.  There  is  here  no  textural  change  in  the  walls  of 
the  vesicles,  and  therefore,  strictly  speaking,  no  emphysema.  Doubtless, 
however,  a  permanent  lesion  may  be  occasioned  by  any  disease  which  has 
long  impaired  the  function  of  the  lung,  especially  when  accompanied  by 
severe  coughing,  as  in  whooping-cough.  We  must  never  forget,  indeed, 
that  whooping-cough  is  the  apparent  origin  of  a  large  number  of  persis- 
tent cases  of  emphysema  and  asthma.  I  have  known  several  such  in- 
stances in  children  who  have  all  their  lives  suffered  more  or  less  from 
dyspnoea  and  palpitation  on  exertion,  the  original  attack  of  whooping- 
cough  having  been  forgotten  or  regarded  as  of  no  importance.  Such 
children  are  thin  and  sometimes  markedly  emaciated ;  are  often,  though 
not  always,  bad  feeders ;  and  not  seldom  have  chronic  winter  cougb. 
The  chest  may  be  also  asymmetrical,  or  more  or  less  of  the  pigeon-breast 
type,  especially  when  there  has  been  much  bronchial  catarrh.  These 
patients  are  often  brought  to  the  physician  as  cases  of  consumption. 

But  little  need  be  said  of  that  form  of  emphysema  known  as  intersti- 
tial, in  which,  owing  as  a  rule  to  violent  coughing,  there  is  rupture  of  the 
vesicles,  and  air  escapes  into  the  interlobular  and  subpleural  tissue,  or,  in 
some  cases,  if  the  opening  does  not  soon  close,  into  the  subcutaneous 
connective  tissue,  where  alone  it  gives  rise  to  diagnostic  signs.  This 
event  is  not  common  nor  in  itself  necessarily  serious,  its  gravity  being 
dependent  on  the  extent  and  permanence  of  its  causative  lesion.  It  is 
said  to  occur  only  in  young  children,  seeing  that  in  them  alone  are  the 
lobules  of  the  lung  separated  by  distinct  intervals  of  connective  tissue.1 

Emphysema,  giving  rise  to  marked  symptoms  and  to  the  characteristic 
expression  of  face  and  figure  so  familiar  to  us  in  adults,  is  not  of  great 
frequency  in  childhood.  When  it  occurs,  it  is  usually  of  the  secondary 
form  and  due  to  severe  and  prolonged  bronchial  catarrh  or  whooping- 
cough.  It  is  not  often  in  childhood  that  we  meet  with  the  consecutive 
events  of  demonstrably  dilated  heart  and  generalised  oedema,  with  con- 

1  I  have,  however,  seen  one  case  of  extensive  subcutaneous  emphysema  in  an  adult, 
occurring  after  the  rapid  removal  of  a  very  large  pleural  effusion  with  much  coughing, 
which  seemed,  after  full  consideration,  to  admit  only  of  this  explanation. 


EMPHYSEMA  AND  ASTHMA.  3  59 

gestion  of  internal  organs,  which  are  so  common  in  later  life.  Of  the 
very  frequent  localised  emphysema  found  post-mortem  in  the  chronic 
lung  disease  of  childhood  and  later  life  it  is  unnecessary  to  speak,  for  it 
has  but  little  clinical  importance. 

The  prognosis  of  emphysema  in  children  is  thus  considerably  better 
than  in  the  adult.  The  tissue  change  which  underlies  so  many  adult 
cases  is  less  frequent  in  children ;  and  much  improvement  or  even  re- 
covery may  take  place.  It  must,  however,  be  remembered  that  there  is 
ample  post-mortem  evidence  of  permanent  structural  change,  even  in 
quite  early  life.  In  pronounced  and  lasting  cases  there  is,  as  in  adults,  a 
liability  to  asthma.  We  must  ever  remember  that  at  all  ages  the  exist- 
ence of  emphysema  adds  much  to  the  gravity  of  all  acute  pulmonary 
affections,  and  at  least  in  adults  is  very  frequently  a  dangerous  basis  for 
an  otherwise  probably  harmless  pneumonia. 

Where  the  affection  is  apparently  primary  the  treatment  must  be 
directed  towards  improvement  of  the  general  nutrition  and  prevention  of 
those  causes  which,  by  favouring  catarrh,  extend  the  disease.  In  the 
secondary  cases,  which  are  at  once  more  frequent,  prominent  and  curable, 
the  treatment  is  mainly  prophylactic  and  remedial  of  the  commonest 
causes, — catarrh  and  inflammation.  A  warm,  dry  climate,  therefore, 
where  the  patient  can  at  the  same  time  enjoy  the  nutritive  effects  of  sun- 
light and  fresh  air,  is  to  be  recommended  when  possible.  A  generous  diet 
and  cod-liver  oil,  iron,  arsenic,  or  all  these  drugs,  are  valuable  aids. 
The  bronchial  catarrh,  which  so  often  is  the  exciting  cause  of  emphysema, 
and  the  frequently  incidental  asthmatic  attacks  are  to  be  treated  by  the 
methods  mentioned  under  those  headings.  By  these  means  we  can  cure 
some  cases,  and  at  least  alleviate  most. 

Asthma. 

By  asthma  I  mean  that  paroxysmal  dyspnoea  with  well-known  clinical 
characters  which,  whether  excited  or  not  by  bronchial  catarrh  or  other 
pulmonary  affection,  seems  always  to  own  a  marked  nervous  or  spasmodic 
element.  In  considering,  however,  this  affection  in  childhood  it  is  con- 
venient to  associate  with  it  the  cases  of  dyspnoea  which  seem  to  be  due 
(whether  frequently  or  not,  authorities  differ)  to  direct  pressure  from 
enlarged  bronchial  glands  on  the  lower  end  of  the  windpipe. 

That  asthma  is,  to  a  very  general  extent  at  least,  an  expression  of 
neurotic  disorder,  as  evidenced  by  its  hereditary  character,  by  its  close 
association  with  other  forms  of  disturbed  nerve  function,  and  by  the 
frequently  sudden  onset  and  departure  of  its  attacks,  which  are  not 
seldom  both  excited  and  allayed  by  so-called  mental  impressions,  is  in 
my  opinion  sufficiently  clear.     The   contention  that  bronchial  catarrh 


360  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

underlies  and  excites  many  if  not  most  cases,  as  it  unquestionably  does 
in  childhood,  in  no  -way  weakens  this  view.  For  often  in  adults,  and 
sometimes  in  childhood,  the  attacks  are  purely  spasmodic,  neither  heralded 
nor  followed  by  sign  of  catarrh  ;  and  all  recognise  the  exceptional  occur- 
rence of  asthma  in  the  course  of  childhood's  bronchitis,  pointing  to  the 
probable  necessity  of  some  other  factor  for  its  production.  I  have  seen 
several  examples  of  purely  spasmodic  asthma  in  children  with  marked 
neurotic  heredity,  where  there  was  absolutely  no  evidence  of  any  affect- 
tion  either  bronchial,  pulmonary  or  glandular.  Yet  in  most  cases  I 
admit  the  association  with  asthma  of  emphysema,  bronchial  catarrh,  or 
broncho-pneumonia.  There  are  several  cases,  indeed,  of  this  latter  disease 
where  prolonged  respiratory  trouble,  unquestionably  due  to  an  asthmatic 
element,  is  for  a  while  mistaken  for  indications  of  greater  gravity,  and  is 
only  rightly  understood  when  a  fresh  review  of  the  case  reveals  a  condi- 
tion of  improved  physical  signs,  and  lessened  or  absent  pyrexia,  incon- 
sistent with  the  diagnosis  of  continued  or  extended  inflammation. 

I  would  call  special  attention  to  the  influence  of  excitement  in  deter- 
mining attacks  of  asthmatic  breathing  in  young  children,  as  in  adults, 
even  in  the  most  ordinary  cases  arising  out  of  bronchial  catarrh.  I  have 
seen  many  instances  of  sudden  onset  and  almost  sudden  departure  of 
these  attacks  in  the  course  of  bronchial  catarrh  of  various  grades,  which 
have  been  believed  at  first  to  be  due  to  pulmonary  inflammation. 

Asthma,  whatever  its  nature  or  exciting  cause,  is  not  often  very  pro- 
minent in  early  childhood ;  and  it  is  somewhat  rare  in  hospital  practice. 
Nevertheless  the  beginnings  of  typical  adult  asthma  can  often  be  traced 
as  far  back  as  the  second  quinquennium  of  life,  or  even  to  a  still  earlier 
period.  Besides  its  very  frequent  association  with  catarrh  and  emphy- 
sema, a  gouty  heredity  can  not  seldom  be  made  out ;  and  I  can  speak  with 
certainty  of  a  few  well-marked  cases  which  strongly  corroborate  the  views 
of  West,  Eustace  Smith  and  others  that  there  is  a  connection  between 
asthma  on  the  one  hand  and  ekzema  and  urticaria  on  the  other.  I  cannot 
go  so  far  as  to  say  that  long-continued  and  extensive  ekzema  is  almost 
always  joined  with  a  tendency  to  asthma;  but  I  have  seen  such  unquestion- 
able examples  of  cured  ekzema  replaced  by  asthma,  which  in  its  turn  dis- 
appeared with  returning  ekzema,  as  to  have  no  doubt  of  the  frequently 
close  pathological  kinship  of  these  affections.  For  the  rest,  as  in  adults, 
inhaled  irritants,  whether  demonstrable  as  dust  or  smoke  or  pollen,  or 
less  determinate  as  emanations  from  animals,  and  also  so-called  climatic 
influences  may  occasion  asthmatic  attacks.  One  of  the  best  examples 
of  asthma  is  that  form  which  is  seen  as  an  expression  of  "hay-fever." 
Keflex  agencies,  such  as  pressure  of  glands  on  the  "  vagus "  nerve,  or 
gastric  disturbances,  seem  to  play  some  causal  part ;  and  polypi  in  the 
nose  and  even  enlarged  tonsils  may  be  included  among  possible  excitants. 


EMPHYSEMA  AND  ASTHMA.  36  I 

Attacks  of  asthmatic  character  are  undoubtedly  often  associated  with 
enlargement  of  the  bronchial  glands,  and  sometimes  in  all  probability,  as 
shown  by  Eustace  Smith,  directly  caused  by  pressure  of  such  glands  on 
the  lower  end  of  the  trachea  or  on  a  main  bronchus.  He  regards  as 
diagnostic  of  this  cause  a  venous  hum  which  is  heard  over  the  upper 
end  of  the  sternum  when  the  head  is  retracted ;  and  teaches  that  this 
bruit  is  due  to  compression  of  the  innominate  vein  between  the  sternum 
and  the  enlarged  glands  in  the  bifurcation  of  the  trachea,  which  are 
carried  forward  with  that  organ  when  it  is  free  to  move  with  the  retrac- 
tion of  the  head.  I  have,  however,  so  often  found  this  symptom  uncon- 
nected not  only  with  asthma  but  also  with  any  other  evidence  of  enlarged 
glands,  and  have  further  seen  post-mortem  markedly  enlarged  glands  in 
this  region  which  have  been  unattended  during  life  by  any  such  signs  or 
symptoms  as  above  recorded,  that  I  cannot  but  question  both  the  leading 
significance  of  the  sternal  bruit,  and  the  predominant  role  of  enlarged 
glands  in  the  production  of  asthma. 

It  must  be  remembered,  in  connection  with  this  subject,  that  a  large 
number  of  cases  of  adult  asthma  begin  before  the  tenth  year  of  life. 

There  is  nothing  special  in  the  symptomatology  of  childhood's  asthma. 
In  the  pure,  but  rare,  cases  unconnected  with  catarrh  the  chest  is  nearly 
fixed  in  the  inspiratory  position,  the  expiration  is  prolonged  and  marked 
by  sibilant  and  sonorous  rhonchi,  and  the  inspiratory  murmur  is  much 
lessened.  The  attacks,  like  other  spasmodic  neuroses,  such  as  epilepsy, 
most  often  occur  at  night.  The  skin  is  moist,  there  is  no  pyrexia,  and 
often  no  cough.  In  the  catarrhal  cases  there  may  be  some  prolonged 
inspiration  as  well,  and  all  degrees  of  moist  rales  may  be  heard.  The 
attacks  here  are  usually  of  more  gradual  onset  and  departure,  and  may 
last,  with  varying  exacerbations  and  remissions,  for  several  days,  weeks, 
or  even  months. 

The  prognosis  in  many  cases  of  bronchitic  asthma  in  childhood  is 
good,  the  symptoms  disappearing  with  its  exciting  cause.  Many  cases, 
however,  last  through  life,  and  I  am  unable  to  give  any  criterion  by 
which  an  accurate  forecast  can  be  made.  I  have  known  cases  of  bad 
chronic  bronchitis  in  quite  young  children,  with  frequent  and  severe 
asthmatic  paroxysms,  which  have  apparently  made  perfect  recovery  after 
wintering  for  a  few  seasons  in  suitable  climates,  and  some  who  have 
similarly  improved  in  spite  of  seemingly  bad  conditions.  Others,  again, 
with  all  medical  care  and  apparent  climatic  advantages,  continued  to  suffer 
for  an  indefinite  period. 

The  less  demonstrable,  perhaps,  the  exciting  causes  of  the  attacks  are, 
whether  bronchial  catarrh  be  present  or  not,  the  more  the  affection  seems 
likely  to  endure. 

Treatment  should  endeavour  to  promote  nervous  health  by  the  hygienic 


362  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

and  medicinal  tonics,  and  to  ward  off  or  remove  all  demonstrable  or 
suspected  exciting  causes,  whether  local  or  general.  Climatic  influences 
are  certainly  very  important  in  many  cases,  though  no  special  rules  on 
this  head  can  be  laid  down  for  all.  The  more  prominent  the  bronchial 
catarrh,  the  more  necessary  it  will  be  to  treat  the  child  on  the  prin- 
ciples indicated  under  the  head  of  chronic  bronchitis.  Iron,  arsenic,  and 
cod-liver  oil  are  sometimes  invaluable ;  and  will  also,  as  far  as  medicine 
goes,  be  suitable  for  those  cases  which  may  be  referred  to  glandular  en- 
largement. Iodide  of  potassium  may  also  be  given  and  is  highly  spoken 
of  by  many ;  but  I  should  hesitate  to  give  this  drug  for  any  long  period 
unless  distinct  improvement  were  clearly  established. 

During  the  attack  the  recognised  remedies  are  all  suitable,  and  have 
apparently  the  same  shares  of  success  and  failure  as  in  the  case  of  adults. 
I  believe  the  breathing  of  nitre  fumes  is  more  frequently  efficacious  than 
most  other  inhalations ;  and  I  feel  sure  that  lobelia  and  belladonna  are 
often  of  very  great  value.  I  have  prescribed  lobelia  largely  at  all  ages 
for  all  varieties  of  asthma,  especially  in  the  more  chronic  forms,  and  have 
never  observed  any  ill  effect  from  it  other  than  occasional  nausea  or  still 
rarer  vomiting.  A  child  of  ten  years  old  will  readily  take  10  minims  of 
the  tincture  every  six  hours.  Depressant  and  nauseating  remedies  are 
undoubtedly  of  service  in  cutting  short  severe  attacks ;  and  for  this 
purpose  full  doses  of  ipecacuanha  may  be  found  useful.  Pilocarpine, 
•j-^th  to  ^th  of  a  grain,  may  also  be  tried  subcutaneously  for  a  child 
between  six  and  ten  years  old.  But  very  severe  attacks  are  rare,  and 
such  treatment  is  but  seldom  called  for. 


CHAPTER    V. 

ACUTE    BRONCHITIS    AND    BRONCHO-PNEUMONIA. 

Both  clinical  and  pathological  considerations  point  to  the  advantage  of 
studying  these  affections  of  the  respiratory  tract  together.  With  almost 
all  cases  of  broncho-pneumonia,  of  whatever  origin,  there  is  generalized 
bronchitis,  as  shown  by  the  examination  of  fatal  cases  or  by  physical 
signs  during  life ;  and  in  severe  bronchitis  of  the  finer  tubes,  which  lasts 
more  than  a  few  days,  some  broncho-pneumonia  is  the  rule,  even  though 
the  physical  signs  of  pulmonary  consolidation  may  be  absent.  The 
passage  is  strictly  gradual,  though  often  extremely  rapid,  from  bronchial 
inflammation  to  exudation  in  the  air-cells.  Acute  general  bronchitis 
and  broncho-pneumonia,  as  seemingly  primary  affections,  are  pre-eminently 


ACUTE  BRONCHITIS  AND  BRONCHO-PNEUMONIA.  363 

diseases  of  young  children,  their  counterparts  in  adults  being  almost 
always  accompaniments  or  sequelae  of  other  maladies. 

By  acute  bronchitis  I  denote  here  the  inflammatory  affection  of  the 
mucosa,  and  sometimes  of  the  deeper  tissues,  which  involves  the  bronchial 
tree  in  all  its  ramifications ;  exclusive  of  those  cases,  already  considered, 
where  the  larynx,  trachea  or  largest  bronchi  pre-eminently  or  solely 
suffer.  The  main  symptoms  of  acute  bronchitis  are  hurried  breathing 
in  proportion  to  the  extent  of  the  bronchial  tree  involved,  feverish ness, 
more  or  less  cough  which  tends  to  diminish  as  the  disease  progresses, 
and  sometimes,  though  almost  exclusively  in  later  childhood,  expecto- 
ration of  mucus  or  muco-pus.  Broncho-pneumonia  in  its  most  frequent 
form,  is,  as  stated,  an  extension  of  this  inflammatory  process  to  the 
smallest  bronchioles  and  air-cells,  leading  to  various  degrees  and  extent 
of  consolidation  of  the  lung ;  and  is  as  a  rule  symptomatically  evidenced 
by  continued  and  increasing  dyspnoea,  more  drowsiness,  and  higher  fever. 

The  conditions  out  of  which  bronchitis  and  broncho-pneumonia  arise  are 
many.  These  affections  occur  both  in  an  apparently  independent  form 
and  also  as  clearly  secondary  to  other  morbid  processes ;  the  observed 
lesions  having  for  the  most  part,  with  the  great  exception  of  many 
tuberculous  cases,  no  differential  relation  to  their  various  sources. 

"  Catching  cold,"  which  is  probably  a  reflex  process  following  on  undue 
exposure  of  the  cutaneous  nervous  surface  and  ending  in  inflammation 
of  mucous  membrane,  seems  to  be  the  only  discoverable  immediate  ex- 
citant in  many  cases ;  and  these  affections  are  unquestionably  far  less 
prevalent  in  the  summer  and  early  autumn  than  in  any  other  part  of 
the  year.  Very  often,  however,  such  exposure  can  be  almost  certainly 
excluded.  It  is  to  be  remarked  that  in  a  very  large  number  of  instances 
the  apparently  primary  attacks  occur  in  children  who  are  badly  nourished. 
Severe  cases  of  acute  bronchitis  and  broncho-pneumonia  are  not  very 
common  among  the  well-to-do,  when  unassociated  with  an  early  tendency 
to  chronic  bronchitis  or  with  some  of  the  other  conditions  now  to  be 
noticed.  Rickets,  7iear£-disease,  7cidney-disea.se,  syphilis,  the  scrofulous 
or  tubercular  diathesis,  and  notably  tuberculosis  itself,  all  favour  or  excite 
the  development  of  catarrh  of  the  air-passages,  although  in  some  of  these 
instances  the  immediate  origin  may  not  be  known.  It  must  never  be 
forgotten  that  chronic  bronchial  catarrh,  dating  from  early  infancy,  is  the 
underlying  condition  of  a  very  large  number  of  cases  of  subacute  and 
acute  bronchitis  of  varying  extent  in  children,  with  or  without  pyrexia. 
Most,  indeed,  of  the  slighter  cases  of  generalized  bronchitis,  in  infants 
which  recover  from  the  attacks,  have  a  history  of  chronic  wheezing  and 
coughing  with  exacerbations  ;  and  these  children  are  usually  anaemic,  thin 
and  weakly.  The  fevers  are  specially  apt  to  occasion  it,  among  which 
measles,  diphtheria,  influenza  and  enteric  fever  are  prominent.     I  have 


364  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

seen,  too,  a  sufficient  number  of  instances  of  bronchitis  and  broncho- 
pneumonia immediately  following  or  accompanying  scarlatina  to  con- 
vince me  of  closer  relationship  here  than  is,  perhaps,  usually  recognised. 
Wliooping-cough  is  almost  constantly  attended  by  some  bronchitis,  aud 
often,  even  in  its  earlier  stages,  by  broncho-pneumonia,  which  in  some 
cases  tends  to  become  chronic.  It  may  be  said,  I  think,  that  bad  nutri- 
tion, whether  due  to  insufficient  alimentation  or  to  definite  disease,  is  one 
of  the  greatest  predisposing  causes  of  acute  bronchitis  and  broncho- 
pneumonia, be  the  exciting  cause  what  it  may.  These  affections  are 
certainly  among  the  most  frequent  scourges  of  poverty. 

The  first  symptoms  of  acute  bronchitis  are  often  those  of  catarrh  of 
the  trachea  and  large  bronchi,  namely  cough,  wheezing,  slightly  increased 
rate  of  breathing  and,  it  may  be,  some  evidence  of  pain  in  the  upper 
sternal  region ;  but  the  dyspnoea  soon  becomes  marked  with  the  rapid 
involvement  of  the  smaller  tubes,  the  cough  often  tends  to  lessen,  and  the 
child  becomes  alternately  restless  and  drowsy.  There  is  mostly  some 
pyrexia,  often  as  high  as  1020 ;  the  face  is  flushed  and,  later,  bluish  ;  and 
there  is  usually  sweating.  The  pulse  is  frequent,  sometimes  exceedingly  ; 
but  as  a  rule  the  normal  pulse-respiration  ratio  is  not  maintained,  the 
respiratory  frequency  being  in  considerable  excess.  An  extreme  case 
of  bronchitic  dyspnoea  is  very  similar  to  that  of  laryngeal  obstruction, 
showing  the  cyanosis,  the  recession  of  the  yielding  parts  of  the  thorax, 
and  the  auxiliary  muscular  action,  without,  of  course,  the  stridor  and  vocal 
loss  which  mark  the  latter  disease.  In  both  cases  the  bronchial  tree  is 
gravely  affected  at  its  root  and  terminal  branches  respectively.  Expec- 
toration but  very  rarely  occurs  ;  for,  at  the  age  most  subject  to  bronchitis, 
children  usually  swallow  any  mucus  which  may  reach  the  pharynx  by 
coughing. 

On  examining  the  chest  at  the  earliest  stage  coarse  rhonchi  or  moist 
rales  may  be  heard,  succeeded  soon  by  finer  sounds  often  audible  over 
the  whole  chest.  The  percussion  note  is  not  necessarily  affected.  In 
cases  which  recover,  without  going  on  to  discoverable  collapse  or  broncho- 
pneumonia, these  signs  diminish  after  a  few  days,  and  usually  disappear 
within  a  week  or  two ;  but  it  must  always  be  remembered  that  it  is 
impossible  to  mark  by  physical  examination  the  initial  stages  of  these 
further  developments.  Small  and  irregularly  distributed  patches  of 
diminished  resonance  without  bronchial  breathing  may,  indeed,  frequently 
be  detected  by  careful  and  light  percussion  in  cases  where  neither 
collapse  nor  broncho-pneumonia  are  of  great  extent ;  but,  on  the  other 
hand,  as  we  shall  see,  there  may  be  many  small  foci  of  broncho- pneu- 
monic consolidation  scattered  over  one  or  both  lungs,  as  proved  in  fatal 
cases,  where  there  have  been  absolutely  no  other  physical  signs  than 
those  of  bronchitis.     Much  cyanosis  is   usually  the  herald  of  death, 


ACUTE  BRONCHITIS  AND  BRONCHO-PNFXMoNIA.  365 

which  is  often  preceded  by  convulsions.  It  may  be  believed,  however, 
that  death  scarcely  ever  follows  on  a  bronchial  inflammation  which 
does  not  also  involve  the  ultimate  bronchioles  and  air-cells.  There  is 
almost  always  some  post-mortem  evidence  of  broncho-pneumonia  in  cases 
which,  during  life,  have  been  styled  capillary  bronchitis. 

Collapse  of  the  lungs  of  greater  or  less  extent  is  a  very  common  event 
in  bronchitis,  occurring  in  most  fatal  cases.  The  parts  involved  can  be, 
as  a  rule,  easily  recognised  post-mortem  by  their  purplish  and  smooth 
appearance,  their  depression  beneath  the  lung  surface,  and  their  capacity 
of  being  inflated  except  in  some  cases  of  ancient  date.  Often,  however, 
in  close  proximity  to  the  collapsed  parts  there  are  patches  of  broncho- 
pneumonic  consolidation,  which,  according  to  its  proportionate  extent, 
obscures  these  marks.  Rickets  adds  much  to  the  chances  of  collapse, 
and  frequently  seems  to  bring  it  about  even  when  the  bronchitis  is  not 
very  severe.  This  fact,  considered  in  connexion  with  what  is  seen  post- 
mortem, and  with  comparison  of  adult  cases  of  bronchitis,  strongly 
corroborates  the  view  of  Fagge  and  others  that  the  immediate  cause  of 
collapse  is  not  plugging  of  the  bronchioles  but  weakness  of  the  inspira- 
tory act,  as  in  the  case  of  simple  atelectasis.  The  younger  and  weaker 
the  child,  the  more  extensive  and  rapid  is  the  collapse.  "When  of  small 
extent,  collapse  may  readily  recover,  disappearing  with  returning  vigoiu-, 
and  may  indeed  do  so  even  in  cases  where  it  is  sufficiently  extensive 
to  cause  diminished  percussion-  and  breath-sounds  or  some  degree  of 
bronchial  breathing.  I  have  repeatedly  made  this  out ;  but  doubtless, 
in  the  larger  number  of  instances  which  quickly  recover,  collapse  is  not 
demonstrable  by  examination  but  can  only  be  inferred  from  increase  of 
respiratory  trouble. 

Broncho-pneumonia,  as  has  been  said,  whatever  its  origin,  is 
nearly  always  preceded  or  accompanied  by  bronchitis,  but  may  arise  so 
quickly  and  progress  so  extensively  as  to  express  almost  from  the  first 
the  physical  signs  of  consolidated  lung,  namely,  more  or  less  impaired 
resonance  on  percussion,  and  bronchial  breathing  especially  marked  on 
expiration.  It  is  these  acute  cases  which  are  often  at  first  and  for  some 
days,  or  sometimes  throughout,  indistinguishable  from  acute  pneumonia 
of  the  lobar  form — a  totally  different  disease.  It  is  doubtless  owing  to 
something  special  in  the  young  child's  respiratory  organs  that  inflamma- 
tion spreads  so  rapidly  from  the  larger  to  the  smaller  tubes  and  to  the 
air-cells ;  and  the  fact  of  the  ultimate  bronchioles  of  infants  being  con- 
siderably larger  in  relation  to  the  air-cells,  which  are  bud-like  dilatations 
from  them,  than  in  the  adult,  may  have  some  causal  connexion  with  this 
clinical  peculiarity.  Besides  this,  the  absence  of  expectoration  in  young 
children  readily  favours  the  inhalation  of  secretion  into  the  lower  air- 
passages.     We  have,  I  repeat,  very  different  sets  of  physical  signs  and 


366  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

post-mortem  appearances  in  the  broncho-pneumonias  of  young  children. 
On  the  one  hand  there  are  the  very  frequent  cases  of  more  or  less 
gradual  onset,  where  fine  mucous  rales,  generated  in  the  smaller  bronchi, 
are  the  predominant  or  even  often  for  a  while  the  sole  physical  signs ; 
but  where  the  accession  of  lobular  consolidation,  with  increasing  fever, 
dyspnoea  and  cyanosis,  is  indicated  in  many  instances  by  more  or  less 
loss  of  resonance  in  disseminated  patches,  over  which  very  fine  and  high- 
pitched  metallic-sounding  rales  are  heard  and,  sometimes,  varying  degrees 
of  bronchial  breathing.  On  the  other  hand  there  is  the  important  class 
of  cases,  by  no  means  always  to  be  differentiated  either  as  to  their  con- 
ditions of  origin,  course,  or  event,  where  a  more  acute  onset  and  exten- 
sive physical  signs  of  consolidation,  frequently  limited  to  one  side,  often 
render  the  diagnosis  from  ordinary  lobar  pneumonia  difficult  or,  for  a 
while,  impossible.  Between  these  two  extreme  examples  we  have  also 
cases  showing  all  degrees  of  intermediate  physical  signs,  according  to  the 
extent  of  the  consolidation  of  one  or  both  lungs. 

Concerning  the  first  kind  I  need  add  but  little  to  what  has  been  already 
said  under  "  acute  bronchitis,"  of  which  it  is  practically  an  advanced  stage. 
The  post-mortem  appearances  are  those  of  discrete  patches  of  lobular 
consolidation  and  collapse,  and  intervening  areas  of  crepitant  lung,  in 
varying  proportions.  There  is  always  evidence  of  bronchitis,  and  the 
small  consolidated  patches  are  grouped  round  bronchial  tubes  filled  with 
secretion.  In  some  cases  the  smallest  bronchioles  and  air-cells  are  laden 
with  pus,  giving  rise  to  an  appearance  which  at  first  sight  simulates 
tubercle.  This  latter  appearance,  however,  may  be  seen  in  the  other 
forms  of  broncho-pneumonia  presently  to  be  mentioned,  and  is  said  by 
Sturges  and  others  to  be  sometimes  met  with  apart  from  much  evidence 
of  general  bronchitis. 

With  regard  to  the  second  kind  of  broncho-pneumonia,  which,  being 
in  many  respects  akin  in  clinical  appearance  to  the  pneumonia  known 
as  lobar,  is  treated  by  some  writers,  under  the  general  heading  of  pneu- 
monia, as  the  "pneumonia  of  children,"  it  behoves  those  who  class 
it  as  I  do  to  point  out  as  far  as  possible  what  distinguishing  clinical 
and  post-mortem  facts  there  are  to  justify  them.  It  has  already  been 
implied  that,  as  far  as  physical  signs  are  concerned,  the  extent  of  the 
consolidation  in  these  cases  is  practically  lobar,  and  post-mortem  exami- 
nation shows  involvement  of  large  areas,  a  whole  lobe,  or  a  whole  lung. 
We  must  rely  for  diagnosis  during  life  on  the  history  and  course  of  the 
case  as  well  as  or  often  more  than  on  physical  signs.  Even  general 
bronchitis,  which  precedes  or  accompanies  most  cases  of  broncho-pneu- 
monia, is  seen  in  some  degree  in  the  true  lobar  pneumonia  of  adults  as 
well  as  children,  and  therefore  cannot  by  itself  be  an  all-important  sign, 
valuable  as  it  is  in  combination  with  others.     Some  little  aid  may  be 


ACUTE  BRONCHITIS  AND  BRONCHO- PNEUMONIA.    367 

gained  by  remembering  the  fact  that  in  the  extensive  broncho-pneumonic 
consolidations  of  children  the  signs  are  very  often  first  observed  at  or 
above  the  root  of  the  lung,  and,  further,  that  the  upper  parts  are  quite  as 
often  affected  as  the  lower.  In  most  cases,  again,  there  is  evidence  sooner 
or  later  of  consolidation  of  both  lungs — certainly  not  a  common  event 
in  the  true  pneumonia  of  children  and  therefore  a  useful  positive  sign ; 
but  of  course  one  of  our  chief  difficulties  in  early  diagnosis  is  in  those 
cases  where  one  lung  at  least  apparently  escapes.  I  would  lastly  say 
that  marked  physical  signs  of  pleural  effusion,  whether  plastic  or  liquid, 
over  the  consolidated  lung  in  an  acute  case,  are  evidence  pro  tanto 
against  broncho-pneumonia. 

Much  light  can  be  thrown  on  many  cases  by  the  previous  history,  for 
in  the  great  majority  of  acute  broncho-pneumonias  there  is  antecedent 
ill-health  of  some  kind,  sometimes  chronic  bronchitis,  and,  exceedingly 
often,  a  recent  attack  of  some  definite  disease  as  previously  alluded  to. 
The  pulse-rate  is  often  much  higher  in  broncho-pneumonia  than  in 
pneumonia  ;  and  diarrhoea  is  much  more  frequent,  owing,  probably,  to  the 
co-existence  of  intestinal  catarrh.  Again,  even  when  the  onset  of  the 
attack  has  been  misleadingly  sudden,  reminding  us  of  true  pneumonia, 
the  course  is  as  a  rule  much  more  irregular  both  as  to  general  symptoms 
and  temperature  ;  recovery  when  it  takes  place  is  gradual ;  and  the  signs 
of  resolution  are  only  slowly  progressive.  There  may  be  frequently 
recurring  exacerbations,  with  a  rise  of  temperature  demonstrably  coin- 
ciding with  the  involvement  of  a  new  area  of  lung;  and  the  normal 
temperature  line  is  often  reached  in  the  intervals.  The  breathing  at  the 
height  of  an  attack  of  broncho-pneumonia  is  usually  much  more  laboured, 
and  cyanosis  more  marked,  than  in  true  pneumonia,  where  it  is  most  often 
merely  hurried.  This  is  probably  due  to  the  much  greater  involvement 
of  the  bronchial  tubes  and  generally  wider  dissemination  of  the  affection 
in  broncho-pneumonia.  The  facts  of  gradual  recovery  and  resolution  of 
the  lung  are  of  the  greatest  importance,  and  in  a  considerable  majority  of 
cases  lead  us,  though  somewhat  late  in  the  day,  to  the  correct  diagnosis. 
I  need  scarcely  say,  however,  that  as  true  pneumonia  has  occasionally  a 
rather  lingering  course,  and  as  its  physical  signs  are  sometimes  obscured 
towards  the  end  by  those  of  pleural  effusion,  the  slow  disappearance  of 
physical  signs  is  by  no  means  pathognomonic.  There  will,  as  yet  at 
least,  remain  a  number  of  cases  in  which  the  diagnosis  cannot  be  made 
during  life. 

Post-mortem  examination  shows  certainly  a  notable  difference  between 
the  lung  in  broncho-pneumonia,  however  acute  the  course  and  however 
extensive  the  consolidation  may  be,  and  the  well-recognised  pneumonic 
lung  of  either  adults  or  children.  The  swollen,  dense  lung,  with  the 
granular  appearance  and  roughish  feel  of  its  cut  surface,  is  found  but 


368  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

in  a  very  small  proportion  of  the  many  children  who  die  with  lung- 
consolidation.  The  broncho-pneumonic  lung  is  less  homogeneous  in 
appearance  and  smoother  on  section ;  and  on  close  inspection  the  lobular 
origin  of  the  morbid  process  can  usually  be  made  out.  The  microscopic 
appearances,  moreover,  show  the  great  preponderance  of  catarrhal  over 
fibrinous  material.  In  most  cases  there  is  evidence  of  disseminated 
lobular  pneumonia  in  both  lungs,  which  may  have  been  unsuspected 
during  life,  and  of  general  bronchitis.  Pleurisy  in  any  of  its  forms  may 
accompany  both  broncho-pneumonia  and  pneumonia  itself;  but  in  a 
marked  or  extensive  degree  is  very  much  less  frequent  in  broncho- 
pneumonia, at  least  in  cases  of  death  at  an  acute  stage.  I  would,  finally, 
repeat  here  what  I  have  said  elsewhere,  that  true  pneumonia,  although 
common  enough  in  quite  young  children  as  evidenced  by  its  typical 
clinical  course,  is  very  rarely  fatal,  unless  double  or  complicated ;  and  that 
on  practical  grounds,  although  I  fully  acknowledge  a  frequent  difficulty 
in  diagnosis,  I  strongly  deprecate  the  classing  together  of  all  extensive 
lung-consolidations  in  children,  however  acute  they  may  be,  under  the 
common  term  of  lobar  pneumonia.  For  the  title  "  lobar  pneumonia  "  is 
mostly  used  as  denoting  the  well-known  disease  which  some  call  "  true  " 
and  others  "  croupous,"  but  to  which  all  accord  a  separate  nosological 
place. 

Broncho-pneumonia  of  whatever  origin  is  far  most  frequent  in  children 
under  three  or  four  years  old,  its  occurrence,  indeed,  being  nearly  limited 
by  that  period,  with  the  exception  of  some  cases  which  are  tuber- 
cular or  are  secondary  to  the  acute  specific  diseases.  Taking  a  con- 
secutive series  of  over  400  cases  from  my  note-books,  which  includes 
none  with  any  diphtheritic  connexion,  I  find  but  very  few  over  this  age 
(and  those  nearly  all  sequent  upon  measles)  which  are  not  certainly  or 
probably  referable  to  tuberculosis,  either  from  definite  signs  and  symp- 
toms, from  their  chronicity  with  wasting,  or  from  post-mortem  appear- 
ances. To  tubercular  broncho-pneumonia  I  shall  again  allude  shortly 
when  considering  tubercular  disease  of  the  lung.  I  will  only  say  here 
that  the  broncho-pneumonia  which  follows  measles  is  very  often  the 
herald  of  pulmonary  and  general  tuberculosis.  Apart  from  tubercle, 
influenza,  enteric  fever  and  some  other  specific  excitants,  the  disease  is 
certainly  almost  unknown  in  adults.  I  have  never  seen  any  such 
instances  of  apparently  primary  broncho-pneumonia  beyond  the  age  of 
childhood  as  are  reported  with  great  precision  by  Dr.  Fagge.  Out  of 
one  unclassified  series  of  43  broncho-pneumonias,  I  find  only  7  over 
three  years  old,  while,  out  of  30  cases  designated  as  true  pneumonia, 
22  are  over  that  age. 

With  regard  to  the  mortality  and  prognosis  of  broncho-pneumonia 
generally,  statistics  are  of  little  value ;  for,  although,  as  I  have  said,  the 


ACUTE  BRONCHITIS  AND  BRONCHO-PNEUMONIA.  369 

determining  conditions  from  which  this  lung  affection  springs  can  rarely 
be  inferred  from  its  clinical  course,  its  mortality  largely  depends  on  its 
origin.  Cases,  however,  are  usually  confused  together  in  note-taking, 
and  broncho-pneumonia  thus  appears  in  the  incorrect  position  of  a  sub- 
stantive disease.  In  comparing,  again,  as  is  often  the  case,  the  mortality 
of  broncho-pneumonia  and  pneumonia  in  children,  we  are  met  by  the 
double  fallacy  of  want  of  attention  to  an  age-limit  and  the  frequent 
falsification  in  the  post-mortem  room  of  the  diagnosis  of  true  pneumonia 
made  in  the  wards.  Taking,  however,  the  age  of  four  as  a  limit,  I 
find  that  the  mortality  of  350  cases  registered  as  broncho-pneumonia 
is  about  35  per  cent.  ;  while  of  42  cases  diagnosed  as  pneumonia  four 
died,  and  the  two  that  were  examined  showed  marked  complications. 
Speaking  very  generally  of  all  cases  together,  the  prognosis  in  broncho- 
pneumonia is  decidedly  grave,  and  I  should  put  the  chances  of  recovery 
as  practically  not  much  more  than  even ;  but  consideration  both  of  the 
probable  origin  and  of  possibilities  of  treatment  are  no  unimportant 
aids  to  our  forecast.  I  know,  however,  no  class  of  cases  in  practice, 
with  the  physical  signs  of  broncho-pneumonia,  which  I  could  speak  of 
as  tending  to  recovery  in  any  considerable  majority ;  for  after  study  of 
my  cases  I  find  but  very  few  of  those,  regarded  by  some  as  simple 
and  as  of  usually  good  prognosis,  which  occur  after  exposure  or  chill  in 
children  who  are  the  subjects  of  neither  recent  and  acute  nor  of  chronic 
or  constitutional  disease.  I  have  seen  more  cases  following  measles  or 
other  fevers  recover,  than  of  those  apparently  sudden  or  "  idiopathic " 
cases  occurring  in  rickety  children  and  others  improperly  fed  and  cared 
for.  Nevertheless  acute  bronchitis  and  broncho-pneumonia  during  an 
attack  of  measles  or  whooping-cough,  especially  in  a  young  child,  are 
very  often  fatal.  Nearly  half  of  my  fatal  cases  were  rickety,  and  most 
of  them  suffered  from  marked  intestinal  disorder,  with  or  without 
vomiting.  On  the  whole  a  persistent  or  oft-recurring  high  temperature 
is  of  very  bad  augury,  as  also,  but  by  no  means  always,  are  marked 
nervous  symptoms,  such  as  retraction  of  the  head,  convulsions,  or  great 
apathy.  The  extent  of  the  lung  mischief,  of  course  an  all-important 
element  in  prognosis,  must  be  judged  of  largely  by  the  general  appear- 
ance of  the  child,  and  by  the  nature  of  its  breathing  and  cough. 

A  rare  event,  according  to  my  experience,  in  acute  broncho-pneumonia 
is  the  formation  of  an  abscess  cavity  of  any  considerable  size.  I  have 
notes  of  only  one  case  which  ran  a  course  simulating  acute  phthisis. 
The  boy,  aged  four,  was  brought  to  the  hospital  two  weeks  after  measles 
with  cough  and  fever,  and  on  examination  the  signs  of  extensive  lobular 
pneumonia  were  found.  After  a  slight  improvement  in  the  symptoms 
the  temperature  rose  to  1030,  the  signs  increased,  and  in  a  fortnight 
there  were  amphoric  sounds  at  the  right  base.     He  wasted  rapidly,  with 

2  A 


370  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

much  sweating,  and  died  four  weeks  after  admission,  the  temperature 
having  never  remitted.  Post-mortem  there  were  found  marked  lobular 
pneumonia  in  innumerable  discrete  patches,  abundant  points  of  pus  in 
the  bronchioles  and  air-cells,  and  a  large  ragged  cavity  containing  pus 
at  the  base  of  the  right  lung.  The  pleura  was  adherent  and  the  bronchi 
were  generally  thickened  and  dilated. 

Tuberculosis  exists  in  many  cases  where  only  broncho-pneumonia  can 
be  diagnosed  with  certainty  ;  and  it  is  more  from  the  family  and  previous 
history,  the  wasting,  and  the  persistently  remittent  pyrexia,  than  from 
physical  signs,  that  we  may  be  able  to  foretell  the  post-mortem  discovery 
of  tubercle.  Some  give  evidence  of  abdominal  tubercle,  and  others  die 
with  meningitis.  Broncho-pneumonia  occurring  in  the  course  of  diph- 
theria is  an  especially  fatal  event,  as  also  is  that  which  follows  on  can- 
crum  oris.  Each  case  must  in  effect  be  judged  carefully  from  all  its 
conditions,  and  from  the  signs  of  vitality,  appreciable  by  the  experi- 
enced observer,  which  may  frequently  aid  a  just  forecast  according  to 
unwritten  laws. 

Besides  the  ending  of  acute  broncho- pneumonia  in  death  or  recovery 
there  is  frequent  evidence  of  a  chronic  condition  which  is  sometimes  mis- 
taken for,  and  sometimes  results  in,  tubercular  disease  of  the  lung.  When 
the  signs  of  consolidation  persist  (especially  when  most  marked  at  the 
apex  in  children  beyond  infancy)  and  cough  and  other  symptoms  remain, 
the  possibility  of  caseation  of  the  lung  must  always  be  remembered. 
Without  entering  into  the  debatable  question  of  the  exact  part  played 
by  the  tubercle  bacillus  in  destructive  lung-disease,  I  am  inclined  to  re- 
cognise a  recoverable  or  arrested  caseation  of  the  lung  which  is  indistin- 
guishable from  that  which  accompanies  tuberculosis.  Broncho-pneumonic 
consolidation  may  thus  be  chronic  ;  some  cases  certainly  ending  in  slow  re- 
absorption  of  the  inflammatory  matter  and  recovery,  and  others  in  ulti- 
mate death  from  persistent  lung-disease,  with  varying  proportions  of 
softening  and  fibrosis.  Instances  of  this  are  quite  frequent  as  a  sequel 
of  whooping-cough.  Lastly  both  acute  and  chronic  pleurisy,  very  often 
purulent,  attend  and  follow  many  cases  of  broncho-pneumonia  whether 
of  simply  catarrhal  or  specific  origin.  The  empyemas  found  in  this  con- 
nexion are  sometimes  quite  small  and  often  variously  loculated.  Dr. 
Sturges  is  inclined  to  hold  that  there  may  be  a  similar  relationship  be- 
tween purulent  broncho-pneumonia  and  empyema  to  that  between  pneu- 
monia and  plastic  pleurisy.  However  this  may  be,  I  have  certainly  seen 
many  empyemas  in  children  beyond  infancy,  as  well  as  the  familiar  cases 
in  adults,  which  followed  directly  on  typical  true  pneumonia. 

An  equable  temperature  of  about  65°,  good  ventilation,  and  hot  moist 
air  to  breathe,  are  the  most  important  means  for  the  best  treatment 
of  cases  of  acute  bronchitis  or  broncho-pneumonia.     All  other  methods 


ACUTE  BRONCHITIS  AND  BRONCHO-PNEUMONIA.  Z7  l 

in  the  early  stage  are  either  unnecessary  or  quite  subordinate,  as  I  have 
been  amply  convinced  by  experience.  A  stuffy  and  over-heated  room, 
with  closed  windows  and  lit  by  gas,  offers  the  surest  conditions  of  tbe 
worst  result.  I  have  often  seen  immediate  improvement  follow  on 
opening  windows  and  forbidding  gas-light,  without  any  further  treatment. 
Too  much  stress  cannot  be  placed  on  this  point.  Everything  that  tends 
to  further  impede  the  mechanical  act  of  respiration  or  to  disfavour  the 
access  of  pure  air  to  the  lung-cells  must  be  rigorously  avoided.  Thick 
poultices,  which  are  obstructive  to  free  breathing,  and,  sometimes,  all 
poultices  and  applications  to  the  chest  other  than  sufficient  to  lessen 
draughts  of  air,  which  are  in  some  circumstances  otherwise  unavoidable, 
must  be  tabooed,  especially  in  small  weakly  children.  The  mere  removal 
of  the  favourite  "jacket-poultice"  will  sometimes  work  wonders.  In 
severe  and  established  cases  I  never  allow  poultices  at  all,  nor  any 
wrap  to  the  chest  except  a  thin  layer  of  cotton  wool  or  wadding ;  for  I 
am  well  assured  of  their  uselessness.  Of  all  methods  of  "  counter- 
irritation"  I  would  say  the  same,  except,  of  course,  in  early  cases  of 
inflammation  of  the  upper  air  passages  and  larger  bronchi,  which  Ave 
are  not  here  considering. 

The  child  should,  when  possible,  be  moved  from  time  to  time  between 
two  rooms,  the  unoccupied  one  being  thoroughly  ventilated  by  open 
windows.  At  the  foot  of  the  bed,  which  should  be  inclosed  by  thin 
curtains  on  a  tent-arrangement,  there  should  be  kept  a  steam-kettle  with 
a  spirit-lamp,  made  on  the  principle  of  the  "steam-draft  inhaler"  intro- 
duced by  Dr.  K.  J.  Lee.  I  have  not  found  special  medications  of 
the  aqueous  vapour  to  be  of  marked  value,  and  after  trying  many  have 
nearly  abandoned  all.  For  medicine,  alcoholic  stimulants  in  small  doses 
are  necessary,  I  think,  where  there  is  great  prostration  and  embarrassed 
heart ;  but  this  drug  should  never  be  given  at  random  in  severe  cases, 
and  should  be  carefully  watched,  for  its  narcotic  effects,  when  there  is 
much  cyanosis  and  drowsiness.  Carbonate  of  ammonia  I  give  in  nearly 
all  cases.  In  the  acutest  cases  with  much  fever  I  have  for  the  most  part, 
until  the  last  few  years,  adhered  to  the  time-honoured  custom  of  giving 
small  doses  of  antimonial  wine ;  but  I  cannot  say  that  I  have  ever  seen 
reason  to  regret  its  omission  in  several  more  recent  instances,  and  no 
longer  give  it  as  a  matter  of  routine.  It  may  serve,  however,  some- 
times to  relieve  the  symptoms  of  cough  and  restlessness.  I  have  never 
known  the  ordinary  sudorifics  act  at  all  in  the  somewhat  few  cases  where 
the  skin  is  very  dry.  So-called  "expectorants,"  such  as  ipecacuanha, 
squills,  and  senega,  I  have  often  tried  and  long  ago  rejected. 

In  serious  cases,  with  cyanosis  and  labouring  heart,  I  have  seen  some 
lives  saved  and  others  at  least  prolonged  by  bleeding.  Leeching  is 
perhaps  the  best  method  for  quite  young  children,  and  cupping,  either  dry 


372  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

or  wet,  for  older  ones ;  but  in  severe  cases  requiring  prompt  assistance 
I  usually  cup,  or  bleed  by  pblebotomy.  The  process  may  be  repeated 
from  time  to  time.  From  half  an  ounce  to  an  ounce  of  blood  may  be 
taken  from  a  child  over  a  year  old,  but  such  directions  are  of  little  value. 
The  amount  should  be  fixed  by  result,  the  finger  being  kept  on  the  pulse, 
and  the  general  condition  of  the  patient  carefully  observed.  When  a 
frequent,  feeble  and,  still  more,  irregular  pulse  improves  markedly  in 
some  or  all  of  these  points,  the  bleeding  should  be  stopped.  In  these 
affections,  even  of  the  severest  form,  there  is  often  some  hope ;  and  I 
would  insist,  from  experience  of  some  few  remarkable  instances,  that 
none  should  be  left  to  die  with  cyanosis  without  some  attempt  being 
made  at  bleeding. 

When  empyema  is  suspected,  exploration  should  be  made ;  and  pus, 
when  found,  should  be  evacuated  at  once,  however  ill  the  patient  may  be. 

To  accelerate  convalescence,  which,  from  the  nature  of  many  cases, 
is  often  very  prolonged,  with  enduring  prostration,  nutritive  and  tonic 
treatment  in  the  widest  sense  is  called  for.  All  care  should  be  taken  to 
prevent  undue  exposure,  but  fresh  air  should  be  secured.  Cod-liver  oil 
should,  I  think,  almost  always  be  given. 


CHAPTER    VI. 

PNEUMONIA. 

Without  discussing  the  various  views  which  have  been  held  as  to  the 
proper  nosological  position  of  acute  pneumonia,  often  styled  "  lobar  "  or 
"croupous,"  I  only  state  here  that  I  regard  it  as  an  independent  fever; 
not  as  a  lung-inflammation  with  symptomatic  pyrexia.  Both  its  clinical 
and  anatomical  characteristics  strongly  support  this  view;  and  recent 
bacteriological  research,  though  failing  as  yet  to  justify  completely  the 
reference  of  this  disease  to  the  action  of  one  specific  germ,  points  with 
the  greatest  probability  to  an  origin  from  the  action  of  organisms  intro- 
duced from  without.  For  what  I  venture  to  deem  by  far  the  best  ac- 
count of  the  nature  and  aetiology  of  pneumonia  generally,  I  refer  the 
reader  to  the  admirable  monograph  by  Sturges  and  Coupland,  and  record 
here  chiefly  the  results  of  my  own  experience  as  to  the  conditions  in 
which  pneumonia  in  children  seems  to  arise.  The  study  of  the  proxi- 
mate causes  of  the  disease  must  always  be  of  great  clinical  importance, 
however  definite  our  future  knowledge  may  be  of  its  essential  origin ; 
and  it  must  be  remembered  that,  while  the  immediate  conditions  out  of 


PNEUMONIA.  373 

which  pneumonia  apparently  springs  are  multiform,  the  best  accredited 
germ,  the  bacillus  of  Fraenkel,  is  frequently  found  in  the  normal  saliva. 

Chill  is  doubtless  an  important  element  in  the  causation  of  many  cases 
which  follow  directly  on  definite  exposure  to  suddenly  occurring  cold, 
especially  when  accompanied  by  wind.  Out  of  200  cases  occurring  in 
my  hospital  practice  rather  more  than  half  were  admitted  in  February, 
March  and  April,  and  less  than  one  fourth  in  June,  July,  August  and 
September.  Several  more  are  recorded  in  May,  October  and  November 
than  in  December  and  January. 

An  apparently  epidemic  form  of  pneumonia  not  seldom  prevails,  and 
several  members  of  one  household  may  be  affected.  I  believe  there  is 
sufficient  evidence  that  bad  drainage  and  other  insanitary  conditions  play 
some  part  in  its  production.  That  the  disease  is  communicable  directly 
from  the  sick  to  the  healthy  I  have  but  little  reason  to  believe  from  my 
own  experience.  Such  communicability,  however,  is  taught  by  some, 
and  appears  to  be  probable  from  several  cases  reported  by  various 
observers.  Dr.  W.  A.  Wills  has  recorded  some  instances  of  apparent 
contagion  from  bed  to  bed  in  vol.  vii.  of  the  Westminster  Hospital 
Reports  (189 1 ). 

In  the  majority  of  cases  pneumonia  is  in  appearance  primary  and  idio- 
pathic ;  in  others  it  is  clearly  secondary,  as  a  part  of,  or  addition  to,  some 
other  demonstrable  disease.  It  may  attack,  in  its  primary  form,  both 
seemingly  healthy  and  delicate  children ;  although,  as  we  shall  presently 
observe,  there  is  a  greater  tendency  in  the  latter  class  to  certain  unfa- 
vourable sequelae. 

As  in  adults,  so  in  children,  pneumonia  begins  suddenly  with  the  well- 
known  symptoms  of  fever,  runs  a  usual  course  of  from  four  to  seven 
days,  and  ends  with  a  more  or  less  rapid  fall  of  temperature.  In  some 
cases  the  fever  lasts  but  two  or  three  days,  or  it  may  be  of  yet  shorter 
duration ;  in  others,  ten  or  even  twelve  days ;  and  in  yet  others,  known  as 
"  pneumonia  migrans,"  it  may  be  of  irregular  course  and  indefinite  period. 
Sometimes  there  is  a  sudden  descent  of  temperature,  followed  by  a  con- 
siderable rise  shortly  preceding  the  ultimate  critical  fall.  Some  of  the 
physical  signs  of  lung  consolidation  almost  always  remain  for  a  while, 
after  the  patient's  practical  recovery  with  the  subsidence  of  the  fever. 

Vomiting  very  frequently  marks  the  onset,  and  may  be  recurrent  for 
several  days.  In  no  disease  of  childhood,  apart  from  definite  cerebral 
mischief,  is  vomiting  so  frequent  as  an  initial  symptom,  scarlatina  standing 
next  in  order  in  this  respect.  Diarrhoea  not  seldom  accompanies  the 
attack  and  may  persist  throughout,  but  constipation  is  more  often 
marked  and  obstinate.  I  have  seen  two  instances  where  this  symptom, 
with  urgent  and  repeated  vomiting,  suggested  the  diagnosis  of  intestinal 
obstruction. 


374  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

Convulsions,  one  or  more,  usher  in  the  disease  less  seldom  than  in 
other  febrile  disorders  of  childhood ;  but  this  symptom  is  not  very  fre- 
quent, and  most  often  implies  rickets  or  some  other  condition  of  nervous 
instability.  Rigors  are  but  rarely  observed  at  the  outset  in  children 
under  five  years  old,  although  I  have  seen  this  phenomenon  occasionally 
at  a  much  earlier  age.  Pain  at  the  epigastrium  or  at  the  side  of  the 
chest  is  often  met  with,  probably  indicating  the  local  pleuritis,  which, 
whether  detected  or  not,  almost  always  accompanies  pneumonia.  A 
bright  flush  on  the  face,  sometimes  limited  to  one  cheek,  is  present  in  a 
very  large  number  of  cases,  occasionally  involving  the  chest  as  well,  and 
sometimes  leading  to  the  mistaken  diagnosis  of  scarlatina.  This  rash, 
however,  should  not  often  deceive  a  careful  and  experienced  observer. 
It  rarely,  if  ever,  occupies  the  arms  or  legs.  Hurried  breathing  marks 
most  cases  from  the  onset,  but  this  symptom  is  often  not  prominent  at 
first ;  and  cough,  which  when  present  is  short  and  hacking,  is  often  in- 
frequent or  even  altogether  absent.  Pronounced  dyspnoea,  or  laboured 
breathing  with  cyanosis,  is  not  a  usual  symptom,  but  is  rather  a  mark  of 
bronchitis  or  broncho-pneumonia.  Nervous  symptoms  are  often  pre-emi- 
nent at  the  beginning ;  and  great  drowsiness  and  apathy,  or  delirium  even 
of  the  wildest  character,  or  severe  headache,  may  throw  all  other  symptoms 
than  pyrexia  into  the  shade.  Occasionally,  too,  there  may  be  temporary 
strabismus.  Such  cases  have  been  named  by  some  observers  "  cerebral 
pneumonia,"  and  are  often  mistaken  for  meningitis.  When,  however, 
delirium  is  prominent  this  mistake  should  never  be  made,  for  delirium  is 
no  marked  sign  of  meningitis.  I  have  notes  of  a  case  where  definite 
pneumonia,  ending  in  good  recovery,  followed  on  a  condition  of  vomiting, 
headache  and  strabismus,  which,  lasting  a  fortnight,  seemed  to  indicate 
cerebral  disease.  A  persistently  rapid  rate  of  breathing  without  irregu- 
larity of  rhythm  is  a  strong  point  in  favour  of  pneumonia  and  against 
cerebral  mischief. 

The  physical  signs  of  the  disease  are  often  later  in  appearance  than  in 
adults,  and  may  indeed  throughout  be  sought  in  vain.  Such  "latent 
pneumonia,"  of  which  I  have  seen  several  unquestionable  examples  that 
have  been  submitted  to  frequent  and  searching  examinations,  must 
always  be  borne  in  mind.  It  can  only  be  accurately  diagnosed  when  the 
course  and  crisis  of  the  disease,  with  the  usual  symptoms  of  altered  ratio 
of  pulse  and  respiration,  have  completed  the  picture.  This  absence  of 
physical  signs  is  probably  due,  as  has  been  often  said,  to  consolidation 
of  deep  seat  and  small  extent,  or  possibly  to  its  entire  absence.  It  is 
to  be  remembered,  however,  that  very  careful  examination  of  the  chest 
will  in  many  cases  detect  early  signs  of  pneumonic  consolidation  which 
escape  the  superficial  observer.  The  earliest  signs  of  all  are  much  dimi- 
nished breath-sound  and  very  slightly  impaired  resonance  over  part  of 


PNEUMONIA.  37  5 

one  lung ;  and  these  signs  may  continue  for  a  while  unattended  by  any 
rales  or  bronchial  breathing.  A  little  later  the  inspiration  becomes 
harsh.  Not  seldom  has  the  recognition,  in  cases  with  pneumonic  symp- 
toms, of  but  a  slight  lessening  of  percussion  and  breath-sound  without 
any  marked  evidence  of  thoracic  trouble,  led  me  to  the  confident  diag- 
nosis of  pneumonia  at  the  very  outset.  The  physical  signs  are  often 
very  limited  in  extent,  especially  when  at  the  apex,  and  sometimes  are 
evident  only  high  up  in  the  axillary  space.  Early  fine  crepitation  is 
perhaps  less  frequent  in  the  child  than  the  adult ;  but  pleural  sounds  are 
very  common,  especially  in  the  lower  lateral  region.  Increased  vocal 
resonance,  as  heard  with  the  cry,  is  often  a  valuable  and  sometimes  the 
predominant  sign  of  consolidation.  For  the  rest,  the  physical  signs  and 
symptoms  in  most  cases  are  very  similar  to  those  in  adults,  with  which  I 
assume  the  reader's  familiarity;  and,  just  as  in  later  life,  the  extent  of 
the  one  has  no  certain  correspondence  with  the  severity  of  the  other. 
The  characteristic  appearance  of  the  blood  in  the  sputum  is  very  rare  in 
early  childhood,  any  expectoration,  indeed,  being  seldom  seen  in  my  ex- 
perience under  ten  years  old.  Drowsiness  throughout  the  disease  is  very 
common  ;  and  real  dyspnoea  is  rare,  however  hurried  the  breathing  may  be, 
except  in  cases  accompanied  by  pleural  effusion  or  when  both  lungs  are 
involved.  It  is  not  usual  to  see  the  large  auxiliary  muscles  of  respira- 
tion at  work,  although  the  dilators  of  the  nose  are  almost  always  active ; 
but  in  severe  cases  with  very  extended  consolidation  there  may  be  inspi- 
ratory retraction  of  the  soft  parts  of  the  thorax  with  every  sign  of  urgent 
dyspnoea.  Herpes  of  the  face  is  not  so  common  in  young  children  as  in 
adults,  and  has  no  specially  favourable  prognostic  value  as  is  believed  by 
some.  It  occurred  in  but  25  cases  (two  of  which  were  fatal)  out  of  135 
which  I  have  referred  to  on  this  point. 

The  temperature  rises  often  to  a  very  high  degree,  even  in  cases  of  no 
marked  severity.  I  have  frequently  seen  it  over  105  and  not  seldom 
over  106.  It  is  usually  at  its  highest  on  the  third  day,  and  has  but  few 
marked  remissions  till  near  the  end. 

Pneumonia  may  attack  children  at  a  very  early  age.  Of  the  above- 
mentioned  135  cases  39  were  under  three.  The  general  mortality  ave- 
rages somewhat  lower  than  is  shown  by  this  list  of  cases  in  which  there 
were  fourteen  deaths,  all  under  four  years  old  (and  mostly  under  two),  with 
the  exception  of  one  case  of  eight  years  old  which  was  complicated  with 
mitral  disease.  Termination  by  crisis  marked  65  (nearly  half)  of  these 
cases,  the  duration  of  the  disease  varying  between  three  and  nine  days. 

The  diagnosis  in  these  early  cases  rested  either  on  a  typical  course 
with  typical  signs,  most  often  with  crisis,  or  on  the  discovery  of  true 
pneumonia  in  those  fatal  cases  which  could  be  examined  post-mortem. 
It  must  be  remembered  here  that,  considering  the  rarity  of  true  pneu- 


376  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

monic  consolidation  post-mortem  and  the  difficulty  in  many  cases  of 
making  a  diagnosis  between  pneumonia  and  broncho-pneumonia  during 
life,  it  is  very  probable  that  some  of  these  fatal  cases  were  wrongly 
classed  as  pneumonia.  In  only  six  out  of  the  fourteen  cases  was  the 
diagnosis  confirmed  by  post-mortem  examination,  and  in  four  of  these 
both  lungs  were  extensively  consolidated. 

Consolidation  of  the  apex  of  the  lung  is  more  frequent  in  children  than 
in  adults,  occurring  in  about  one-fourth  of  all  cases,  and  perhaps  more 
often  in  those  under  three  years  old.  Although  more  frequently  accom- 
panied by  delirium  than  the  basic  kind,  it  has  an  equally  favourable 
course.  Of  the  only  two  fatal  cases  of  apical  pneumonia  among  the 
above,  one  had  extensive  double  consolidation,  and  the  other  had  jaun- 
dice, pleural  effusion  and  diphtheria.  The  right  lung  suffered  at  the 
apex  far  more,  and  at  the  base  considerably  less  often  than  the  left. 
Seven  cases  were  double,  of  which  four  were  fatal.  Jaundice  occurred 
in  two  cases,  the  lung-consolidation  being  left-sided  in  one. 

Of  meningitis  in  pneumonia  I  can  say  but  little  from  personal  ex- 
perience, and  I  am  in  accord  with  those  authorities  who  consider  the 
meningitis  primary  in  the  case  of  concurrence  of  the  two  affections  as 
demonstrated  by  an  autopsy.  It  is  further  probable,  as  taught  by 
Sturges  and  Coupland,  that  these  cases  are  of  septic  origin ;  and  they  are 
probably  allied  to  the  epidemic  form  of  cerebro-spinal  meningitis  which 
is  often  accompanied  by  pneumonia.  One  case  that  I  have  seen  began 
with  convulsions,  followed  by  well-marked  symptoms  of  meningitis  which 
lasted  three  weeks  before  apical  signs  of  pneumonia  developed,  and  per- 
sisted for  a  while  after  resolution  of  the  lung.  The  temperature  was  but 
slightly  raised  and  often  not  above  normal,  a  vesiculo-pustular  eruption 
appeared  on  the  face  and  limbs,  and  there  was  discharge  from  one  ear. 
This  case  ultimately  recovered  perfectly.  The  well-known  nervous 
symptoms  at  the  onset  of  pneumonia,  including  delirium,  occasional 
squinting  and  headache,  are  not  justly  to  be  referred  to  meningitis.  I 
would  call  attention  here  to  the  fact  that  we  very  occasionally  meet  with 
pneumonia  accompanied  by  extremely  slight  and  evanescent  pyrexia. 

In  much  the  larger  number  of  cases  there  is  a  rapid  cessation  of 
symptoms  with  a  rapidly  falling  temperature,  the  critical  sweating  being 
very  often  present,  but  sometimes  substituted  by  a  critical  diarrhoea.  A 
more  gradual  fall  of  temperature  and  gradual  improvement  (lysis)  is, 
however,  of  no  less  favourable  import,  nor  is  there  any  material  difference 
in  average  duration  between  these  otherwise  similar  sets  of  cases. 

A  certain  proportion  of  pneumonias  merge  into  pleurisies,  serous  or 
purulent ;  the  signs  of  fluid  being  superadded  to  those  of  consolidation, 
or  following  on  them  at  a  shorter  or  longer  interval.  Marked  dulness, 
remaining  more  than  a  week  or  so  after  the  proper  symptoms  of  pneu- 


I'XEUMONIA.  377 

monia  have  disappeared,  should  always  be  regarded  as  a  likely  indication 
of  fluid ;  and  a  small  exploratory  syringe  should  then  he  used  for  diag- 
nostic purposes.  Such  exploration  should  he  made  even  if  there  he  hut 
slight  or  no  rise  of  temperature.  Although  persistent  pyrexia,  per- 
sistent dulness,  and  diminished  breath-sounds  are  doubtless  the  most 
frequent  signs  of  empyema,  I  have  seen  a  large  number  of  cases  where 
pus  was  plentiful  and  fever  absent.  Termination  in  empyema  is,  1 
think,  more  common  than  is  generally  suspected,  although  it  occurs  in  a 
small  minority  of  cases.  The  history,  however,  of  many  empyemas  points 
to  an  onset  exactly  like  that  of  pneumonia.  It  is  moreover  well  worth 
remembering  that  Fraenkel's  diplococcus,  the  microbe  which  has  the 
most  claim  to  be  regarded  as  causal  in  pneumonia,  has  been  found  in 
many  empyemas  ;  and  that  better  (as  quoted  by  Sturges  and  Coupland) 
infers  from  his  observations  that  the  greater  number  of  purulent  pleu- 
risies in  childhood  are  "  pleuresies  a  pneumocoques."  A  certain  amou7it 
of  coarse  bronchitis  occurs  in  the  pneumonia  of  children  more  often  than 
in  adults ;  and  pericarditis  is  from  time  to  time  observed,  as  evidenced 
either  by  friction  or  by  the  signs  of  liquid  effusion.  Pericarditis,  however, 
of  any  extent  or  duration  should  excite  the  suspicion  of  rheumatism,  of 
which  pneumonia  at  all  ages  is  from  time  to  time  an  expression. 

The  diagnosis  of  true  pneumonia  in  early  childhood  is  often  a  matter 
of  some  difficulty,  owing  to  the  frequently  lobar  distribution  of  the 
physical  signs,  with  a  sudden  onset  of  symptoms,  in  cases  whose  concomi- 
tants and  results  show  that  they  are  of  broncho-pneumonic  nature.  This 
difficulty  is  especially  met  with  in  the  broncho-pneumonia  which  accom- 
panies or  follows  measles,  whooping  cough,  and  other  acute  diseases. 
Nevertheless  in  most  instances  the  abundant  rales  which  usually  precede 
and  throughout  accompany  the  signs  of  consolidation  in  broncho-pneu- 
monia (not  only  over  the  consolidated  part  where  they  are  usually  fine 
and  metallic  in  character,  but  also  over  the  chest  generally  on  both 
sides),  and  the  more  prolonged,  indefinite  and  remittent  course  of  the 
pyrexia,  generally  give  valuable  help  towards  an  early,  if  not  an  initial, 
diagnosis ;  while  the  termination  of  the  disease  will  often  clear  up  the 
doubt  which  may  remain.  That  there  are,  however,  severe  cases  of  acute 
broncho-pneumonia  which  begin  with  comparative  suddenness,  and  end 
in  as  short  a  time  as  pneumonia,  must  be  fully  recognised ;  and  the  true 
diagnosis  cannot  here  be  arrived  at  until  the  case  is  well  or  dead,  and 
sometimes  not  at  all.  Broncho-pneumonic  and  pneumonic  consolidation, 
moreover,  may  co-exist,  as  evidenced  by  post-mortem  examination ;  and 
in  such  cases  the  clinical  and  physical  signs  must  of  course  be  con- 
fused. But  with  all  this  admitted  difficulty  I  would  insist  on  the 
fact  of  true  pneumonia,  as  diagnosed  from  its  typical  symptoms  and 
course,  being  very  common,  and  for  the  most  part  an  easily  distinguish- 


378  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

able  disease,  in  young  children.  It  should  never  be  confused  in  thought 
with  broncho-pneumonia,  whatever  diagnostic  difficulty  we  may  meet 
with  in  practice;  nor  should  the  rare  discovery  of  the  typically  "pneu- 
monic "  lung  at  post-mortems  in  childhood  induce  us  to  hesitate  in  our 
diagnosis,  for  we  have  seen  that  pneumonia  in  early  years  in  its  ordinary 
form  is  an  essentially  benign  disease.  I  need  not  repeat  in  detail  the 
widely  different  physical  signs  of  a  typical  pneumonia  and  a  typical 
broncho-pneumonia  ;  but  content  myself  with  emphasising  the  fact  that 
in  the  one  they  are  as  a  rule  unilateral  and  prominent,  in  the  other 
bilateral  and  obscure ;  and  that,  while  rales  are  mostly  absent  in  the  one 
during  the  height  of  consolidation  and  sometimes  in  the  stages  both  of 
ingravescence  and  resolution,  in  the  other  they  are,  as  a  rule,  continuously 
predominant. 

Of  the  diagnosis  between  pneumonia  and  meningitis  I  have  already 
spoken.  The  predominance  of  cerebral  symptoms  often  creates  a  sus- 
picion of  primary  brain  trouble ;  but  suddenly  occurring  high  fever  with 
delirium  and  burning  heat  of  skin  in  a  previously  healthy  child  should 
always  suggest  pneumonia,  and  this  diagnosis  should  not  be  abandoned 
even  when  the  physical  signs  are  long  delayed  or  are  ultimately  of  the 
slightest  kind. 

Enteric  fever  in  children  especially  often  begins  suddenly  with  con- 
siderable pyrexia  and  headache,  and  is  thus  liable  to  be  diagnosed  in 
place  of  pneumonia,  especially  when  there  is  diarrhoea  in  addition.  The 
flushed  face,  and  some  signs  or  symptoms  of  pneumonia  which  as  a  rule 
reveal  themselves  to  the  careful  observer,  generally  clear  up  the  difficulty ; 
but  we  must  recognise  occasionally  the  impossibility  of  being  positive  in 
our  diagnosis  at  first,  however  closely  we  study  the  case.  Delirium  is 
very  rare  quite  at  the  outset  of  enteric  fever. 

The  mortality  of  primary  pneumonia  in  children  is,  as  we  have  seen, 
but  small.  Much  involvement  of  both  lungs  is  unfavourable,  as  also  is  a 
very  frequent  and  irregular  pulse.  A  large  pleural  effusion  is  both  rare 
and  of  bad  prognosis.  In  short,  all  complications  are  elements  of  more 
or  less  gravity.  Especially  is  this  the  case  when  extensive  bronchitis  or 
broncho-pneumonia  co-exists  with  the  pneumonic  attack.  The  ultimate 
result  of  those  cases  which  end  in  empyema  will  be  treated  of  with  the 
subject  of  pleurisy.  Secondary  pneumonias,  occurring  in  the  course  of 
other  affections,  such  as  Bright's  disease,  acute  rheumatism  and,  very 
rarely,  enteric  fever,  are  all,  in  varying  degrees,  of  more  serious  import 
than  those  which  are  regarded  as  primary ;  as  also  are  the  cases  which 
are  distinctly  epidemic  in  character,  or  of  probable  septic  origin.  It  is 
among  this  class  of  cases,  and  perhaps  especially  the  nephritic  ones,  that 
we  occasionally  meet  with  the  grey  hepatisation  of  lung  well  known 
in  adults. 


PLEURISY.  379 

The  prevailingly  favourable  course  of  pneumonia  in  early  life  renders 
all  attempts  at  active  treatment  as  unnecessary  in  principle  as  they  are 
demonstrably  useless  in  practice.  The  patient's  diet  should  be  liquid, 
and  the  drink  copious,  slightly  acidulated  with  lemon.  In  the  height  of 
the  fever  a  simple  saline  mixture  may  be  given  whenever  it  is  deemed 
desirable  to  prescribe  something.  Acetate  of  ammonia  with  spirit  of 
nitrous  ether  will  sometimes  relieve  thirst  and  possibly  may  promote 
diaphoresis ;  although,  when  the  temperature  is  high  and  the  skin  dry 
and  hot,  this  result  is  but  rarely  attained  even  with  very  large  doses. 
If  the  fever  be  excessive,  quinine  in  full  doses,  from  one  to  five  grains 
according  to  age,  and  frequent  sponging  with  tepid  or  cold  water, 
should  be  ordered.  I  entirely  disapprove  of  cold  baths  in  those  severe 
cases  which  are  supposed  by  some  to  indicate  the  use  of  this  remedy; 
and,  having  had  but  little  occasion  to  try  ice- compresses  to  the 
chest,  can  say  nothing  as  regards  this  alleged  remedy.  The  diarrhoea 
which  is  not  uncommon  in  pneumonia  is  of  no  grave  import,  and  scarcely 
ever  requires  to  be  checked  by  art.  If  it  be  very  profuse,  we  should 
empirically  use  astringents  or  opium,  if  not  otherwise  contra-indicated. 
When  dyspnoea  and  cyanosis  are  great,  and  the  case  is  therefore  grave, 
leeches,  from  four  to  eight  in  number,  should  be  applied  to  the  chest 
Avails,  where  pressure  can  be  used  to  arrest  bleeding,  if  necessary  ;  or  dry 
cupping,  which  is  more  prompt  in  action,  may  be  prescribed.  "When 
there  is  much  co-existent  bronchitis,  the  case  should  be  treated  with  a 
steam-tent,  as  advised  in  broncho-pneumonia ;  and  ammonium  carbonate 
and  alcohol  should  be  given.  If  pain  be  great  and  there  be  no  markod 
signs  of  impeded  aeration  of  the  blood,  I  always  advise  occasionally 
repeated  doses  of  Dover's  powder,  regulated  according  to  age ;  and  hot 
fomentations  or  poultices  should  then  be  applied  to  the  chest.  I 
regard  pain  as  the  chief  or  only  indication  for  poultices,  and  deprecate 
their  general  use,  especially  in  severe  cases,  as  tending  to  hamper  the 
breathing. 


CHAPTEE    VII. 
PLEURISY. 

Although  it  is  the  purulent  form,  or  "  empyema,"  which  pre-eminently 
concerns  us  in  discussing  the  diseases  in  early  childhood,  pleurisy  in  both 
its  plastic  and  serous  varieties  is  frequently  met  with. 

The  question  of  the  aetiology  of  this  affection  demands  some  notice 
here,  for  the  prevailing  belief  in  idiopathic  acute  pleurisy,  or  in  simple 


380  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

pleurisy  due  to  chill  or  "cold,"  is  mainly  based  on  superficially  apparent 
cases  of  this  nature  which  are  not  at  all  infrequent  in  childhood.  Of 
this  origin  for  the  disease,  however,  I  have  the  gravest  doubts  ;  and  long 
experience  and  study  of  numerous  cases  have  caused  me  to  teach  for 
many  years  that  what  is  called  simple  pleurisy  is  almost  as  rare  in  the 
child  as  it  certainly  is  in  the  adult,  and  is  practically  of  but  little  account. 
Pleurisy  is  almost  always  a  secondary  affection,  occurring  in  the  course 
or  as  a  sequel  of  some  antecedent  or  more  general  disorder ;  and  I  am 
convinced  that  the  more  this  practical  truth  is  borne  in  mind  the  better 
our  prognosis  will  be. 

The  first  generalisation  which  will  probably  be  made  by  an  experienced 
observer  of  pleurisy  in  children  is,  that  apparently  simple  cases  arising 
out  of  no  definitely  demonstrable  disease  are  very  rare  among  the  children 
of  the  well-to-do,  though  at  first  sight  common  enough  among  those  of  the 
poor ;  and  the  next,  that  a  very  large  majority  of  cases  of  all  kinds  and 
in  all  conditions  are  distinctly  referable  to  some  antecedent  illness,  either 
local  or  general.  Out  of  one  series  of  108  patients  with  liquid  pleurisy, 
serous  or  purulent,  taken  consecutively  from  my  hospital  case-books,  35 
were  admitted  as  pneumonia  or  broncho-pneumonia ;  and,  of  the  remaining 
73,  only  12  were  stated  to  have  been  well  before  the  pleuritic  attack  for 
which  they  were  admitted.  An  acute  onset  with  pain  on  one  side  or  in 
the  abdomen  was  noted  in  31  of  these  73;  while  in  the  rest  (42)  the 
origin  of  the  affection  was  symptomatically  indefinite,  most  of  them 
having  been  ill  for  several  months,  usually  with  cough,  and  many  having 
never  been  well  since  measles  or  whooping-cough  months  or  years 
before.  Of  the  31  with  acute  beginnings,  4  were  definitely  rheumatic, 
6  demonstrably  tubercular,  and  2  undoubtedly  traumatic ;  leaving  only 
19  which  could  with  any  show  of  probability  be  put  down  to  the  score 
of  primary  acute  pleurisy.  By  far  the  larger  part  of  these  108  cases 
were  empyemas. 

In  another  series  of  18  cases,  all  plastic  or  serous  in  nature,  ranging 
from  1^  to  13  years  old,  I  find  two  only  with  a  clean  bill  of  health  before 
attack.  Seven  had  either  tubercle  or  a  very  strong  tubercular  history, 
and  five  had  never  been  well  since  measles  or  whooping-cough  some 
months  before.  Two  were  rheumatic  and  had  heart-disease,  and  in  the 
remaining  two  the  onset  was  insidious  and  origin  undiscovered.  These 
patients,  with  the  exception  of  two  who  died  with  tuberculosis,  completely 
or  partially  recovered  from  the  pleural  attack,  which  began  with  pain  in 
the  side  or  belly  in  nearly  half  the  cases. 

Among  liquid  effusions  occurring  in  childhood,  and  following  on  or 
connected  with  broncho-pneumonia  or  pneumonia,  empyema  is  about 
twice  as  frequent  as  serous  pleurisy. 

In  yet  another  series  of  21  cases,  all  empyemas,  in  children  varying 


PLEURISY.  38 1 

from  one  to  nine  years  old,  3  were  definitely  pneumonic  in  origin, 
2  broncho-pneumonic,  3  scarlatinous,  2  tubercular,  and  2  traumatic.  In 
six  there  was  a  history  of  long  illness  with  cough,  beginning,  in  half  of 
these,  after  measles;  and  in  the  remaining  three  the  symptoms  are  reported 
to  have  set  in  acutely  with  fever,  pain  in  the  "chest"  or  "stomach," 
vomiting,  or  rigors.  It  would  appear  that  in  only  these  last  three  cases 
could  a  primary  origin  be  claimed  at  all ;  and  it  is  certainly  possible,  and 
in  my  opinion,  most  probable,  that  they  were  pneumonic.  An  initial 
rigor  points  in  all  likelihood  to  coexistent  pneumonia,  as  is  also  taught 
by  Fraentzel.  Moreover,  in  the  cases  quoted  above  as  of  indefinite  origin, 
and  especially  those  following  on  measles,  a  broncho-pneumonia  is  very 
likely  to  have  occurred. 

I  am  well  assured  of  the  usually  secondary  character  of  pleurisy,  from 
my  experience  both  of  children  and  of  adults ;  and  desire  to  lay  special 
stress  on  this  point,  owing  to  the  little  emphasis  or  occasional  doubt  ex- 
pressed thereon  by  most  authorities,  and  to  the  frequent  and  sometimes 
disastrous  mistakes  I  have  seen  made  in  practice  by  those  who  hold 
the  popular  view  that  this  affection  is  of  but  trifling  import.  The  harm 
arising  from  such  mistaken  prognostics  is  not  confined  to  the  patients 
and  their  friends,  but  often  seriously  damages  professional  reputation. 

To  sum  up  : — Pneumonia  and  broncho-pneumonia  account  for  a  very 
large  number  of  pleurisies,  both  purulent  and  serous,  and  tubercle  is  a 
very  frequent  cause.  Acute  rheumatism  gives  rise  to  many  plastic  and 
serous  effusions,  and  measles  and  scarlatina  head  the  list  of  those 
numerous  fevers  or  septic  diseases  of  which  empyema  is  an  accom- 
paniment or  sequel.  The  affection  is  not  uncommon  in  Bright's  disease, 
and  is  seen  occasionally  in  syphilis.  Direct  traumatism,  including  falls 
or  blows  which  may  bruise  the  pleura  with  little  or  no  external  injury, 
accounts  for  a  certain  number  of  cases  of  both  serous  and  purulent 
pleurisy ;  as  also  does  extension  of  inflammation  from  neighbouring 
structures  or  abscesses,  including  those  below  the  diaphragm.  Other 
occasional  causes  are  not  few,  but  need  not  be  detailed. 

The  onset  of  pleurisy  in  childhood  is  very  often  insidious  and  there- 
fore unobserved.  Although  a  considerable  proportion  of  plastic  and 
serous  cases  begin  with  the  classical  symptoms  of  pain  in  the  side  or 
epigastrium,  and  with  a  hacking,  short  cough,  yet  these  are  more  often 
wanting  than  in  adults ;  and  by  far  the  larger  number  of  empyemas  are 
unattended  at  first  by  thoracic  symptoms,  and  often  unsuspected,  until 
prolonged  illness  with  pronounced  wasting  and  pallor  and  more  or  less 
dyspnoea  at  last  incites  some  one  to  examine  the  chest. 

It  is  not  possible  to  draw  a  hard  and  fast  line  between  either  the 
symptoms  or  signs  of  serous  and  purulent  pleurisy. 

Empyema,  especially  among  the  poorer  classes,  is,  as  we  have  seen, 


382  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

one  of  the  common  wasting  diseases  of  children.  It  is  much  less  often  unac- 
companied hy  some  pyrexia,  continued  or  remittent,  than  the  serous  form ; 
but  the  temperature  may  he  scarcely  raised  or  even  normal.  Diarrhoea 
is  often  seen  with  chronic  empyema ;  and  a  waxy  yellow  colour  of  the 
skin  is  very  common,  even  in  cases  of  short  duration.  Clubbing  of  the 
fingers  and  toes  is  frequent  and,  as  a  rule,  a  mark  of  chronicity.  I  have 
not  observed  the  unilateral  occurrence  of  this  phenomenon.  In  cases 
where  there  is  evidence  of  fluid  in  the  pleura  the  exploring  needle  only 
can  decide  definitely  on  its  nature,  and  it  is  therefore  useless  to  detail  or 
discuss  the  varying  observations  and  mere  opinions  which  have  been 
recorded  with  reference  to  differential  diagnosis  on  this  point.  In  all 
pleural  effusions,  where  the  liquid  is  free  or  nearly  free  in  the  cavity, 
marked  displacement  of  organs  is  more  common  in  children  than  in 
adults.  This  is  chiefly  evidenced  by  the  altered  position  of  the  heart's 
impulse ;  or,  where  this  cannot  be  established,  as  not  seldom  happens,  by 
the  absence  of  the  impulse  from  its  proper  place  and  the  detection  of  the 
heart's  new  position  by  auscultation.  As  in  adults,  so  in  children,  the 
displacement  of  the  heart  is  greater  and  more  likely  to  cause  disturbed 
action,  both  as  regards  regularity  and  frequency,  when  the  effusion  is  on 
the  left  side.  At  the  same  time  I  would  observe  that  I  have  but  rarely 
seen  marked  cardiac  embarrassment  in  the  pleurisies  in  children ;  and 
never  a  fatal  issue,  as  recorded  by  some,  and  attributed  to  twisting  of 
the  vena  cava.  Clotting  in  the  pulmonary  artery  is  perhaps  the  most 
frequent  cause  of  death  in  those  extremely  acute  cases  of  pleurisy,  more 
often  seen  in  adults,  with  rapidly  increasing  effusion  which  seriously 
compresses  the  lung.  On  the  whole,  too,  dyspnoea  is  less  marked  in 
children  than  in  adults.  I  have  seen  several  instances  in  young  children 
of  extensive  effusion  which  scarcely  interfered  with  their  playing  or 
running  about. 

The  usual  symptoms  and  physical  signs  of  non-purulent  pleurisy  in 
children  are  as  follows.  There  is  generally  hurried  breathing  in  propor- 
tion to  the  amount  of  effusion,  a  hacking  cough,  and  pale  complexion. 
With  those  rare  effusions  which  rapidly  occupy  the  whole  of  one  pleura, 
the  dyspnoea  may  be  extreme  and  the  face  cyanosed,  the  opposite  lung 
being  in  a  condition  of  great  hypersemia,  and  the  right  heart  much 
embarrassed.  Such  cases  call  for  instant  aspiration  to  relieve  urgent 
symptoms  or,  possibly,  to  save  life.  The  temperature  is  not  often  high, 
rarely  much  over  ioi°.  Pain  in  the  side  is  often  felt  at  the  onset,  and 
may  be  almost  the  only  symptom  when  lymph  alone  is  effused.  When 
the  inflammation  is  confined  to  the  diaphragmatic  pleura,  epigastric  pain, 
occasional  vomiting,  and,  though  very  rarely,  abdominal  tenderness  will 
probably  mark  the  case.  More  or  less  impaired  movement  of  the  affected 
side  is  usually  seen';  and  friction  sound  is  generally  heard,  if  examination 


PLEURISY.  383 

be  made  at  the  outset,  but  is  often  missed  from  its  short  duration  in  cases 
which  go  on  to  effusion.  It  is  always  detectable  during  the  period  of 
absorption,  and  in  dry  pleurisy  may  persist  for  an  indefinite  time.  It  is 
especially  frequent  in  the  axillary  and  infra-mammary  regions.  The 
friction  sound,  heard  often  over  the  lower  ribs  on  one  side  in  diaphrag- 
matic cases,  is  not  seldom  an  important  diagnostic  sign,  aiding  us  in 
detecting  the  thoracic  nature  of  an  apparently  abdominal  attack.  In 
free  liquid  effusion  there  is  dulness  on  percussion,  extending  from  the 
posterior  to  the  anterior  base,  unlike  the  dulness  of  basic  pneumonia, 
which  but  rarely  extends  in  the  anterior  direction.  The  dulness  is  more 
intense,  and  percussion  causes  a  far  greater  sense  of  inelasticity  or 
resistance,  than  in  pneumonia.  Above  the  level  of  the  fluid,  when  the 
effusion  does  not  fill  the  pleural  cavity,  there  is  almost  always  a  sub- 
tympanitic  note  on  percussion.  But  little  is  usually  learned  from  exa- 
mination for  vocal  fremitus,  owing  to  the  high  pitched  voice  of  young 
children,  and  to  the  ready  transmission  of  the  vibrations,  when  present, 
from  the  unaffected  lung.  The  heart  may  be  felt  beating  at  various 
distances  from  its  normal  position  by  the  hand  placed  on  the  chest, 
the  most  marked  example  of  this  being  found  when  a  large  left-sided 
effusion  pushes  the  heart's  impulse  far  over  to  the  right. 

Auscultation  detects  much-exaggerated  breath-sounds  on  the  healthy 
side  (giving  rise  sometimes  to  the  diagnosis  of  lung-affection  in  that 
position),  and  diminution  or  complete  abolition  of  vesicular  breathing  on 
the  affected  side.  Very  often  bronchial  breathing,  sometimes  in  a  most 
marked  degree,  is  heard  all  over  the  area  of  effusion,  and  exaggerated  or 
puerile  breathing  above  the  level  of  dulness. 

A  very  large  number  of  effusions  are  circumscribed,  especially  when 
purulent.  They  may  be  very  small,  occasioning  much  difficulty  in 
physical  diagnosis,  and  often  escaping  even  frequent  exploratory  punc- 
tures. There  may  also  be  more  than  one  collection  of  fluid  completely 
isolated  by  adhesions.  I  once  drew  off  serum  by  one  puncture  and  pus 
by  another  on  the  same  side  of  the  chest,  at  the  same  sitting.  In  cases 
of  some  standing  the  diagnosis  between  thickened  pleura  alone,  and  the 
same  condition  with  pus-collection  somewhere,  is  quite  impossible  with- 
out exploration.  In  general,  when  the  exploring  syringe  or  trocar,  well 
thrust  in,  seems  to  be  firmly  held  and  is  withdrawn  unstained  by  pus 
or  blood,  the  diagnosis  of  thickened  or  gelatinous  pleura  at  that  spot 
may  be  made  with  confidence ;  while  the  appearance  in  the  syringe  or 
aspiration  bottle  of  pure  blood  in  any  quantity  would  probably  indicate 
puncture  of  the  lung.  In  cases  where  combined  fever,  wasting  and 
other  symptoms  point  to  active  disease,  repeated  exploration  should  be 
made  at  various  points  of  dulness. 

The  events  of  pleurisy  are  very  different  according  to  the  nature, 


384  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

extent  and  duration  of  the  effusion.  Some  plastic  pleurisies  may  be 
entirely  absorbed;  but  not  seldom  they  leave  more  or  less  adhesive 
thickening,  with  or  without  physical  signs.  Serous  effusions,  even  of 
magnitude  and  many  weeks'  duration,  may  ultimately  be  absorbed,  but 
very  often  result  in  thickened  pleura,  marked  by  dulness  and  lessened 
breath-murmur,  with  or  without  friction  sounds  either  single  or  double ; 
and  the  affected  side  of  the  chest  may  fall  in  when  there  are  adhesions, 
causing  more  or  less  deflection  of  the  spinal  column,  with  the  concavity 
towards  the  lesion.  Similar  results  to  these  last,  but  more  marked, 
extensive  and  frequent,  may  follow  empyemas  which  are  spontaneously 
absorbed  or  which  recover  after  one  or  more  aspirations.  Empyemas, 
however,  far  more  often  become  chronic ;  and,  if  unrelieved  by  opening 
and  draining  the  pleural  cavity,  lead  to  profound  wasting  accompanied, 
as  a  rule,  by  fever  of  varying  degree,  and  to  death  from  exhaustion. 
Amyloid  disease  may  be  another  result  of  unrelieved  or  chronic  empyema ; 
and  tuberculosis  may,  as  in  other  diseases,  supervene,  encouraged,  it 
may  be,  by  the  morbid  condition  induced  by  the  suppuration.  In  some 
cases  the  pus  points  outwardly  at  the  surface  of  the  thorax,  or,  after 
burrowing  the  tissues,  at  other  parts  of  the  body,  both  internal  and 
external ;  in  others  it  is  freely  expectorated,  with  much  coughing,  after 
penetrating  a  bronchus,  while  occasionally  it  is  discharged  in  both  of 
these  modes.  Fibroid  induration  of  the  lung,  with  or  without  marked 
dilatation  of  the  bronchial  tubes,  is  also  in  some  cases  a  result  of  chronic 
pleurisy,  both  purulent  and  non-purulent.  A  careful  study  of  the  natural 
history  of  empyema  in  childhood  leads  to  the  conclusion  that  the  ulti- 
mate prognosis  is  for  the  most  part  bad  if  the  cases  be  not  actively 
treated ;  and  the  practical  lesson  I  have  learned  from  experience  is  to 
aspirate  at  once  and  fully  when  the  diagnosis  of  pus  is  established, 
regardless  of  the  absence  of  symptoms  of  pressure  on  the  lung,  which  is 
so  frequent  in  localised  empyemas.  Should  the  general  health  improve 
and  there  be  no  fever,  local  treatment  must  then  yield  to  general,  until 
there  be  farther  indication  for  interference  from  increase  or  reappearance 
of  physical  signs. 

I  have  seen  several  cases  of  empyema  recover  well  after  one  aspira- 
tion. But,  if  there  be  hectic  fever  or  any  sign  of  deterioration  of  the 
patient,  I  invariably  have  the  cavity  opened  and  drained  antiseptically, 
without  losing  time  by  a  second  aspiration.  I  have  ample  evidence, 
from  the  comparative  results  of  my  earlier  and  later  cases,  that  incision 
of  the  pleura  without  delay  is  completely  successful  in  many  instances ; 
and  am  further  convinced  that  the  modern  plan  of  sub-periosteally 
excising  a  portion  of  one  or  more  ribs  is  almost  always  advisable,  as 
conducing  at  once  to  better  drainage  in  all  cases  (whether  the  lung 
can  re-expand  itself  or  not),  and  to   the  earlier  closing  of  the  pleural 


PLEURISY.  385 

fistula  by  aiding  the  chest-walls  to  fall  in  when  the  lung  is  per- 
manently crippled.  Difficult  as  it  undoubtedly  is  in  some  instances 
to  drain  and  close  the  anfractuous  cavities  of  a  long-standing  loculated 
empyema,  I  have  the  records  of  numerous  cases,  where  the  chest  has 
been  opened,  resulting  in  perfect  expansion  of  the  lung,  with  no  deformity 
of  the  thorax,  nor  any  other  trace  of  the  disease  than  some  comparative 
dulness  and  the  surgical  scar.  In  many  cases,  indeed,  the  scar  alone 
has  remained  to  mark  the  side  which  suffered.  Among  these  successful 
cases  several  are  included  where  the  pus  was  so  thick  that  it  could  not 
be  aspirated,  where  there  were  many  adhesions,  and  where  the  pleura 
had  to  be  freely  and  extensively  scraped,  being  entirely  occupied  by  a 
gelatinous  effusion. 

Between  this  complete  success,  and  as  complete  occasional  failure  with 
fistulous  opening  and  wasting  unto  death,  there  may  be  all  grades  of 
thoracic  deformity  with  impaired  health.  I  have  sometimes  seen  a 
very  good  result  from  the  spontaneous  evacuation  of  an  empyema  either 
through  the  chest  wall  or  through  the  lung.  Nevertheless  "  Natura 
medicatrix  "  scores  but  few  successes  here,  and  her  efforts  should  always 
be  prevented  by  surgical  art.  I  would  mention  here  that  I  believe  very 
many  empyemas  are  such  from  the  beginning,  purulent  conversion  of 
a  serous  effusion  being  certainly  rarer  than  is  generally  believed.  A 
serous  effusion  may  remain  serous  for  an  indefinite  time. 

As  to  the  diagnosis  of  pleurisy  in  children,  we  must  remember  that 
it  is  often  very  difficult  or  impossible  to  distinguish  between  pleural  and 
pulmonary  sounds  by  auscultation  alone,  and  that  pleural  sounds  are 
often  heard  at  a  spot  where  puncture  may  prove  the  existence  of  fluid. 
The  great  frequency  of  loculated  effusions  must  remind  us  to  examine  for 
such  collections  not  only  at  the  base  but  also  at  other  parts  of  the  chest ; 
for  a  circumscribed  empyema  may  be  situated  even  at  the  apex  of  the 
lung.  Careful  examination  will  almost  always  lead  to  a  correct  diagnosis 
between  lobar  pneumonia  and  pleural  effusion.  I  therefore  refrain  from 
repeating  the  physical  signs  of  these  well-known  conditions,  and  omit 
the  familiar  but  useless  and  generally  misleading  disquisition  of  the 
text-books  on  a  difficulty  which  is  only  occasional.  If  in  any  case  of 
chest  affection  there  be  persistent  local  dulness  with  absent,  muffled, 
or  tubular  breathing,  and  even  accompanied  by  additional  sounds  of 
undetermined  character,  an  empyema  is  at  least  probable  ;  and  an  explora- 
tory puncture  should  be  used  for  diagnosis  when  possible.  It  is  in  the 
chronic  cases  that  the  difficulty  of  distinction  between  fluid  effusion  and, 
for  instance,  a  solid  fibroid  lung  or  thickened  pleura  may  arise ;  and  it  is 
just  in  these  cases  that  a  puncture,  which  so  often  removes  all  diagnostic 
doubt,  can  be  performed  without  exciting  objection  or  causing  risk.  In 
some  cases  however  of  small  loculated  empyemas  even  frequent  explo- 

2  B 


$86  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

ration  is  unsuccessful.  Change  of  level  of  dulness  with  change  of  the 
patient's  position  is  a  sign  of  fluid  at  all  ages ;  but  the  diagnosis  in  such 
cases  is  usually  already  certain,  and  the  absence  of  this  phenomenon  has 
no  importance,  considering  the  frequency  in  childhood  of  thickened  pleura 
with  adhesions  and  loculi.  The  diagnosis  between  tubercular  or  other 
consolidation  of  the  lung  and  a  pleurisy  confined  to  the  apex  must  be 
made  more  from  general  consideration  of  the  history  and  symptoms  of 
each  individual  case  than  from  physical  signs  alone. 

The  prognosis  in  pleurisy  largely  depends  on  the  causation  of  the 
case  in  question,  being  generally  bad  in  very  early  infancy,  when  it 
is  usually  purulent,  and  in  cases  of  marked  diathetic  disease,  such  as 
the  "  scrofulous  "  condition.  Serous  pleurisy  usually  recovers,  at  least 
approximately,  even  in  tubercular  subjects,  provided  the  underlying 
disease  be  not  advanced  elsewhere.  It  is,  however,  neither  in  children 
nor  in  adults  to  be  regarded  without  apprehension  as  to  its  ultimate 
meaning,  for  it  is  frequently  but  one  indication  among  others  of  serious 
and  general  disease.  I  have  seen  several  cases  discharged  as  cured,  which 
were  subsequently  the  victims  of  phthisis. 

In  all  empyemas  the  prognosis  is  better  in  proportion  to  the  complete- 
ness of  the  evacuation  of  the  pus  and  the  early  institution  of  surgical 
treatment.  In  few  diseases  does  the  ultimately  perfect  or  partial  cure 
depend  so  much  on  skilful  and  assiduous  treatment,  both  surgical  and 
medical.  By  far  the  larger  number  of  the  many  complete  cures  of 
empyema  occur  in  those  cases  which  are  the  result  of  pleuro-pneumonia. 

For  the  treatment  of  pleurisy  we  seek  to  relieve  pain  and  discomfort, 
to  antagonize  the  conditions  out  of  which  the  disease  seems  to  arise,  and 
to  evacuate  pus,  when  present,  out  of  regard  not  only  to  the  local  trouble 
it  may  cause  but  also  to  the  general  and  ulterior  mischief  it  entails.  In 
the  comparatively  rare  cases  of  acute  dry  pleurisy  discovered  at  the  outset, 
counter-irritation,  with  Rigollot's  mustard  leaves  or  a  blister,  quickly 
lessens  or  removes  the  pain,  and  may  perhaps  arrest  the  inflammation 
and  prevent  liquid  effusion.  When,  however,  liquid  effusion  has  occurred, 
no  special  treatment  is  called  for  or  is  in  the  least  efficacious  unless  the 
symptoms  of  pressure  on  the  lung  are  so  great  as  to  demand  instant 
aspiration.  I  have  seen  on  the  one  hand,  in  a  sufficiently  large  number 
of  serous  effusions,  such  a  rapid  re-absorption  in  their  natural  course  as 
to  preclude  belief  that  this  process  can  be  hurried  by  any  drug  treat- 
ment ;  and  on  the  other  hand  my  failures  in  attempting  to  reduce 
chronic  effusions  by  means  of  so-called  absorbent  medicines,  among 
which  potassium  iodide  is  still  in  the  best  repute,  have  been  too  fre- 
quent to  warrant  the  teaching  that  the  occasional  disappearance  of  fluid 
under  this  treatment  is  to  be  regarded  in  the  light  of  an  effect. 

In  allpleurisies,  other  than  serous  cases  due  to  traumatism  or  those 


PLEURISY.  3S7 

occurring  in  the  actual  course  of  a  rheumatic  attack,  a  diet  as  generous 
as  the  patient  can  take,  and  iron,  cod-liver  oil,  arsenic,  or,  in  fact,  any 
effectual  aids  to  good  nutrition,  are  to  be  recommended,  not  forgetting 
the  dictates  of  general  hygiene.  Cardiac  stimulation  either  by  alcohol 
or  ammonia  is  often  indicated  by  the  state  of  the  circulation.  I  have 
no  reason  whatever  from  experience  to  believe  that  curtailing  the  amount 
of  liquid  in  the  diet  promotes  the  absorption  of  a  pleural  effusion ;  and,, 
further,  a  dry  diet  is  practically  out  of  the  question  when  any  fever  is 
present  which  abolishes  appetite  and  impairs  digestion. 

I  have  already  spoken  of  the  imperative  necessity  of  evacuating  pus, 
in  whatever  quantity  it  may  be  present ;  and  must  leave  most  of  the 
details  of  this  treatment  of  empyema  to  the  province  of  the  surgeon.  I 
would  but  add  here  that  Potain's  aspirator  with  a  medium-sized  trocar 
should  be  used  in  the  first  instance  ;  that  the  puncture  should  be  made, 
not  at  the  extreme  base,  but  preferably  in  the  sixth  space ;  that  if  the 
fluid  re-appear,  or  the  general  symptoms  demand  it,  the  thorax  should 
be  opened  with,  as  a  general  rule,  sub-periosteal  resection  of  a  piece  of 
one  or  two  ribs  according  to  strict  antiseptic  methods  ;  and  that  a  drain- 
age tube,  shortened  from  time  to  time,  should  be  inserted,  securely  fixed, 
and  retained  until  the  discharge  ceases  and  the  wound  is  healing.  In 
all  cases,  unless  otherwise  indicated,  the  chest  should,  in  my  opinion,  be 
opened  either  in  or  behind  the  mid-axillary  line,  in  spite  of  the  preference 
of  some  surgeons,  on  various  accounts,  to  make  the  incision  further  forward. 

~No  washing  out  of  the  chest  is  required  unless  the  discharge  be  foetid, 
or  there  be  reason  to  believe  that  there  is  much  adhesion  and  inspissated 
and  retained  pus,  which  is  often  indicated  by  persistently  raised  tempera- 
ture, scanty  discharge,  and  retarded  healing  of  the  fistula.  In  this  case, 
as  also  when  the  usual  marked  improvement  fails  to  follow  on  the 
operation,  another  opening  may  be  necessary,  and  the  chest  may  be  from 
time  to  time  washed  out  with  an  aqueous  dilution  of  tincture  of  iodine 
(half  a  drachm  to  the  ounce)  or  a  solution  of  boracic  acid.  In  aspirating 
a  large  effusion  I  can,  from  experience,  strongly  recommend  the  precaution 
of  occasionally  suspending  the  flow  of  fluid  for  a  few  minutes  in  all 
cases.  Positive  indications  for  this  are  fits  of  coughing,  and  any  evidence 
of  embarrassed  breathing  or  heart  action. 

As  soon  as  the  child  is  well  enough  to  be  moved,  which  is  often  long 
before  the  discharge  has  ceased,  he  should  be  encouraged  to  take  exercise 
short  of  fatigue,  and  placed  in  conditions  where  he  can  obtain  as  much 
fresh  air  and  sunlight  as  possible. 

Pleurisy  with  effusion,  especially  empyema,  is  sometimes,  though  not 
very  often,  double.  The  prognosis  is  then  graver  than  in  the  ordinary 
unilateral  cases,  but  the  principles  of  treatment  are  the  same.  There  is 
no  reason  to  wait  for  the  healing  of  the  incision  wound  on  one  side 


388  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

before  opening  the  other  pleura.  I  have  lately  had  two  cases  of  double 
empyema,  one  recovering  perfectly  after  a  single  aspiration  on  each 
side,  a  second  exploration  finding  no  fluid ;  the  other  showing  an 
equally  good  result  after  a  preliminary  double  aspiration,  and  subsequent 
opening  and  draining  of  both  sides  of  the  chest,  with  a  fortnight's 
interval  between  the  last  two  operations.  There  is,  however,  I  believe,  no 
reason  for  more  than  a  day  or  two's  interval,  or  perhaps  even  a  much 
shorter  one,  between  opening  the  two  pleurae. 

As  a  valuable  illustration  of  the  excellent  result  obtained  in  empyema 
after  resection  of  rib,  I  add  the  following  short  account  of  several  cases 
examined  at  various  periods  after  discharge  from  the  children's  hospital. 
The  observations  were  made  in  1891  at  my  suggestion  by  Dr.  Hastings, 
then  Resident  Medical  Officer,  who  kindly  took  the  trouble  of  trying  to 
find  out  all  the  cases  which  had  been  in  hospital  during  a  period  of  eight 
years.  Out  of  a  very  large  number,  only  twenty-four  came  up  for  exami- 
nation. Of  these,  two  cases  were  examined  seven  years,  four  between 
four  and  five  years,  two  between  three  and  four  years,  seven  between  two 
and  three  years,  six  between  one  and  two  years,  and  three  less  than  one 
year,  after  discharge  from  hospital.  Nineteen  cases  were  under  six  years 
old,  including  two  of  one  year  and  six  of  two  years,  the  remainder  varying 
from  seven  to  thirteen  years.  Most  of  them  had  either  been  noted,  or 
with  great  probability  regarded,  as  arising  out  of  an  acute  attack  of  pleuro- 
pneumonia. As  regards  symptoms  at  the  time  of  the  examination 
referred  to,  in  two  cases  there  was  stated  to  be  occasional  pain  in  the 
affected  side,  and  in  eight  there  was  some  cough,  severe  in  only  one.  Of 
these  eight,  four  had  slight  bronchitic  signs,  one  granular  pharyngitis, 
two  shortness  of  breath  on  exertion,  and  in  one,  where  the  discharge  had 
continued  for  two  years,  there  was  some  evidence  of  dilated  bronchi.  In 
the  rest  there  was  no  complaint  at  all.  The  general  nutrition  was  good 
in  nineteen  cases,  and  fair  in  five.  Not  one  looked  wasted  or  ill.  As 
regards  physical  signs,  inspection  of  the  chest  in  the  majority  of  the  cases 
gave  no  indication  of  disease  beyond  the  presence  of  the  scar.  The 
spine  was  straight  in  nineteen  cases,  distinctly  curved  in  only  two,  and 
the  shoulders  were  of  the  same  height  in  fifteen.  In  fourteen  the  move- 
ments of  both  sides  of  the  chest  were  equal ;  in  two  only  was  there 
distinct  deficiency  on  the  affected  side.  Percussion  showed  no  dulness 
at  all  in  eight  cases ;  localised  dulness  in  the  region  of  the  scar  in 
twelve ;  and  distinct  dulness  of  more  extensive  area  in  four.  To 
auscultation  the  breath  sounds  were  quite  normal  in  ten  cases,  and  more 
or  less  weakened  over  greater  or  less  areas  in  the  rest.  In  only  one 
were  there  any  adventitious  sounds  limited  to  the  affected  side. 

The  position  of  the  heart's  apex  beat  was  little,  if  at  all,  altered  in  a 
large  majority  of  these  cases. 


ON  PHTHISIS  AND  MEDIASTINAL  GLAND  DISEASE.       389 

It  must  be  remembered  that  in  almost  all  of  the  patients  deformity  of 
the  chest,  impaired  movement,  dulness,  and  weakness  of  breath  sounds 
were  conspicuous  on  discharge  from  hospital,  even  when  the  wound  was, 
as  was  usual,  quite  healed.  This  series  of  cases,  however,  amply  proves 
the  great  frequency  of  good  recovery  of  the  lung  after  greater  or  less 
lapse  of  time. 


CHAPTER  VIII. 

ON    PHTHISIS    AND    MEDIASTINAL    GLAND    DISEASE. 

Most  that  is  special  to  our  subject  in  the  clinical  and  pathological  aspects 
of  destructive  pulmonary  disease,  or  "phthisis"  in  its  widest  sense,  is 
mainly  confined  to  cases  in  children  below  the  age  of  about  six  years. 
After  this  age  we  meet  with  more  and  more  instances  of  "  consumption 
of  the  lungs  "  of  the  patterns  familiar  to  us  in  adults,  where  the  symptoms 
and  signs  of  chest-mischief  are  greatly  predominant,  and  where  anatomical 
examination  shows  that  the  destructive  process  has  begun  in  the  lungs 
and  is  mainly  or  sometimes  almost  entirely  localised  therein.  Until  the 
age  of  about  three  years  the  largest  number  of  cases  of  tuberculosis 
of  the  lungs  show  also  more  or  less  generalised  tubercle  in  the  other 
great  cavities  and  in  the  lymphatic  glands,  evidenced  often  by  special 
symptoms ;  and  thus  many  more  instances  are  met  with  than  in  adults 
Avhich  have  the  prominent  clinical  aspect  of  either  cerebral  or  abdominal 
disease.  Again,  as  we  have  already  seen  when  considering  the  subject 
of  tuberculosis  generally,  examples  are  frequent  of  advanced  tubercular 
disease,  in  the  lungs  as  well  as  in  other  parts,  where  both  the  symptoms 
and  physical  signs  during  life  have  been  indistinctive  of  their  true  cause, 
consisting  often  of  wasting  and  fever  with  but  slight  evidence  of  pul- 
monary catarrh;  and  we  also  meet  with  other  cases  where,  still  with  only 
general  symptoms  and  but  slight  cough,  extensive  disease  in  the  lung 
during  life  may  be  established  by  physical  examination. 

From  the  clinical  point  of  view,  therefore,  I  shall  regard  as  phthisis  or 
pulmonary  consumption  only  those  cases  in  young  children  where  the 
symptoms  and  signs  of  lung  disease  are  prominent ;  and  shall  treat  shortly 
of  their  chief  points  of  difference  from  their  counterparts  in  later  life 
Concerning  the  anatomical  basis  of  phthisis  in  children,  it  may  be  said 
here  once  for  all,  without  entering  into  discussion  as  to  whether  all  cases 
are  strictly  tubercular  in  origin  or  not,  that  there  is  practically  the  same 
variety  of  appearances  in  the  lung  at  all  ages.  "We  meet  with  tubercle 
in  all  its  states  and  combinations,  whether  caseous,  grey,   or  miliary, 


39°  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

softening,  obsolescent  or  obsolete ;  and,  though  less  frequently,  with  all 
degrees  of  fibrosis.  There  is  also,  as  in  adults,  a  great  variety  of  signs 
and  symptoms.  As  a  general  rule,  with  the  exception  of  those  cases 
of  somewhat  doubtful  origin  hereafter  to  be  noticed  under  the  name  of 
"  fibroid  disease,"  phthisis  in  children,  with  all  varieties  of  lung  appear- 
ances, tends  to  run  a  much  shorter  average  course  than  in  adults;  and  hence 
we  meet  with  fewer  cases  of  advanced  cavitation  or  of  much  fibrosis  as  a 
sequel  of  tubercular  mischief.  After  a  careful  review  of  my  experience, 
and  reference  to  my  case-books,  I  am  constrained  to  say  that  it  seems  as 
impossible  to  make  any  clinically  valuable  classification  of  the  phthisis  of 
childhood  according  to  the  anatomical  appearances  found  post-mortem,  as 
it  is  of  that  in  later  life.  I  cannot  recognise  any  important  clinical 
differences  either  between  the  so-called  "  pneumonic  "  and  the  so-called 
"tubercular"  cases  of  acute  onset  and  rapid  course,  or,  again,  between 
the  more  chronic  forms  which  are  similarly  differentiated  by  some 
authorities.  There  are  doubtless  many  cases  of  broncho-pneumonia 
in  young  children,  where  the  signs  of  consolidation,  usually  in  one 
lung,  endure  for  long  with  perhaps  some  slight  fever,  cough,  and  wast- 
ing. Many  of  these,  as  we  have  seen,  recover ;  while  more  go  on  to 
phthisis,  with  softening  and  cavitation  of  caseous  matter  as  shown  post- 
mortem, and  with  both  lungs  affected.  Whether  the  consolidation  of 
lung  that  recovers  be  caseous,  or  if  caseous,  already  tubercular  or  not, 
that  which  ultimately  breaks  down  and  is  soon  followed  by  a  similar 
affection  of  the  other  lung  is  assuredly  and  confessedly  tubercular.  I 
cannot  therefore  but  regard  the  clinical  facts  of  phthisis,  in  children  and 
adults  alike,  as  quite  corroborative  of  the  pathological  tenet  that  almost 
all  destructive  disease  of  the  lung  is  ultimately  tubercular ;  although  it 
seems  at  least  probable  that  the  chronic  inflammatory  or  perhaps  even 
caseous  process  may  last  for  some  time  (as  for  instance  in  the  case  of 
many  broncho-pneumonias)  unaffected  by  tubercle,  and  ultimately  re- 
cover perfectly.  Such  cases  may  indeed  be  said  to  be  almost  the 
monopoly  of  early  childhood,  a  period  when  tuberculosis  is  as  a  rule 
so  fatal.  For  some  time,  however,  both  as  regards  physical  signs  and 
general  symptoms,  they  may  be  clinically  indistinguishable  from  those 
which  prove  to  be  destructive  tubercular  disease. 

The  apparent  differences  in  the  various  clinical  forms  of  phthisis  are 
probably  due  to  constitutional  and  environmental  circumstances  which 
cause  the  infective  tubercular  process  or  bacillary  activity  to  be  more 
limited  and  more  readily  checked  in  some  instances  than  others.  In 
children,  as  in  adults,  some  cases  run  a  symptomatically  severe  course 
with  disproportionately  small  extent  of  lung-disease ;  while  others  may 
have  considerable  local  mischief  for  long,  with  but  few  grave  symptoms. 
In  the  former  class  of  cases,  however,  we  usually  find  evidence  of  some 


ON  PHTHISIS  AND  MEDIASTINAL  GLAND  DISEASE.        39  I 

more  generalised  tubercle ;  while  in  the  latter  the  tubercular  process  pro- 
bably spreads,  and  spreads  slowly,  from  its  primary  seat  alone.  The 
only  classification  of  pulmonary  phthisical  affections  that  I  regard  as  in 
any  way  useful  is  very  general,  and  is  much  the  same  as  that  adopted  by 
Professor  Jacobi.  (i.)  Acute  miliary  tuberculosis,  without  marked  or 
any  signs  of  consolidation,  which  may  be  almost  confined  to  the  lungs 
and  begins  usually  in  caseation  of  the  bronchial  or  mediastinal  glands. 
These  cases  are  not  very  common,  and  are  as  a  rule  rapidly  fatal.  (2.) 
Ordinary  phthisis,  or  the  "  caseous  pneumonia  "  of  authors.  This  often 
arises  out  of  broncho-pneumonia  or  out  of  caseous  disease  of  the  bron- 
chial glands ;  and  may  run  either  an  acute  or  somewhat  chronic  course, 
with  various  degrees  of  signs  of  consolidation,  sometimes  slight  and 
mainly  shown  by  bronchophony  with  little  dulness,  at  other  times 
extensive  with  all  the  usual  characters.  In  many  cases  there  is  tem- 
porary, and  sometimes  apparently  permanent,  recovery ;  but  there  is 
always  a  liability  to  fresh  outbreaks,  and  to  acute  miliary  tuberculosis 
of  the  lung  or  other  parts,  especially  of  the  brain  and  pia  mater.  (3.) 
Chronic  phthisis,  of  various  antecedents  and  often  very  slow  course ; 
marked  by  considerable  fibrosis  of  lungs,  or,  in  some  cases,  by  extensive 
fibrosis  of  one  lung  only,  and  by  a  tendency  to  symptomatic  quiescence. 
This  third  class,  however,  as  we  shall  see,  is  one  of  heterogeneous  content, 
and  is  to  be  considered  apart  only  from  reasons  of  practical  convenience. 

Of  the  acute  form  of  miliary  tuberculosis  almost  confined  to  the 
lungs  I  need  say  little  more  here,  the  affection  being  not  common  in 
childhood,  and  even  rare  in  young  children.  The  physical  signs  are 
usually  only  those  of  catarrh  and  are  therefore  not  distinctive ;  and  the 
diagnosis  is  to  be  made  from  a  careful  consideration  of  the  case  in  the 
light  of  a  knowledge  of  the  general  characters  of  acute  tuberculosis.  We 
must  remember  that,  practically,  a  large  majority  of  cases  of  tuberculosis 
of  the  lungs  of  any  form  is  included  in  the  category  of  general  tuber- 
culosis. In  suspected  cases,  ophthalmoscopic  examination  for  choroidal 
tubercle  should  be  remembered ;  and  due  note  made  of  the  fact  of  high 
but  remittent  temperature,  often  showing  the  remittence  in  the  later 
part  of  the  day. 

In  the  second  and  ordinary  form  of  pulmonary  phthisis  common 
to  all  ages,  acute  or  subacute,  and  characterised  post-mortem  by  grey 
or  caseous  tubercular  deposits,  with  or  without  miliary  tubercle,  there 
are  some  points  to  be  noticed  as  more  or  less  special  to  children.  In  the 
majority  of  cases  below  the  age  of  four  or  five,  and  in  some  as  old  as  five 
or  even  six  years,  the  lung-disease  begins,  not  at  or  near  the  apices  of 
the  lungs,  as  is  the  rule  in  older  children  and  adults,  but  either  at  the 
root  or  in  the  lower  lobes,  thus  depriving  us  of  one  of  the  chief  elements 
in  the  physical  diagnosis  of  adult  phthisis,  based  on  our  knowledge  of 


392  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

the  usual  progress  of  tubercular  disease  from  above  downwards.  The 
infrequency  of  cavitation,  moreover,  of  such  extent  at  least  as  to  give  rise 
to  unequivocal  auscultatory  phenomena,  is  a  further  hindrance  to  the  right 
interpretation  of  the  varying  pulmonary  signs  we  discover,  which,  con- 
sidered by  themselves,  are  easily  confused  with  those  of  non-phthisical 
affections  such  as  pneumonia,  broncho-pneumonia,  or  pleurisy.  Tuber- 
cular disease  of  the  lung,  often  beginning  at  the  root,  is  here  like 
broncho-pneumonia,  which  is  so  frequently  an  extension  of  bronchitis 
and  at  the  same  time  not  seldom  a  forerunner  of  tubercle.  I  must 
nevertheless  insist  on  the  fact  that  at  the  age  of  about  four  years,  when 
pulmonary  tuberculosis  begins  from  its  somewhat  longer  course  to  assume 
gradually  the  familiar  symptomatic  characters  of  phthisis  as  seen  in 
adults,  there  is  a  very  notable  minority  of  cases  where  the  disease  does 
start  at  the  apices  and  proceed  downwards.  Of  this  I  have  seen  many 
examples. 

Expectoration  is  decidedly  a  less  marked  symptom  in  young  children 
than  in  adults,  and  we  are  frequently  thus  left  without  the  diag- 
nostic help  of  microscopical  examination  for  bacilli  and  lung-tissue.  It 
is  none  the  less  true  that  in  phthisis  we  meet  with  a  great  exception 
to  the  general  rule  of  the  absence  of  expectoration  in  the  pulmonary 
diseases  of  children  under  seven  or  eight  years  old;  for  I  have  seen 
numerous  cases  as  young  as  four,  and  some  younger,  where  expectoration 
was  considerable  or  even  profuse.  Haemoptysis  is  certainly  not  so  fre- 
quent as  in  adults ;  but,  though  seldom  excessive,  is  by  no  means  rare. 
Eapidly  fatal  haemoptysis,  arising  from  aneurysms  or  erosion  of  vessels  in 
cavities,  is  very  rare,  owing,  probably,  to  the  usually  shorter  course  of 
juvenile  phthisis;  but  instances  of  both  may  be  met  with.  The  tem- 
perature charts  show  nothing  very  peculiar  ;  progressive  tuberculosis,  with 
little  or  sometimes  no  pyrexia,  of  which  I  have  seen  some  instances  like 
those  reported  by  Henoch,  being  mostly  confined  to  wasted  infants  of 
low  vitality.  One  more  point  to  be  insisted  on,  at  the  risk  of  some 
repetition,  is  that  a  considerably  greater  liability  obtains  in  phthisical 
children  generally,  than  in  adults,  to  tubercular  disease  elsewhere,  as 
marked  by  symptoms  of  both  head  and  abdominal  mischief.  The 
younger  the  patient — and  this  applies  as  well  to  the  years  beyond 
childhood — the  more  frequent  are  cerebral  tuberculosis,  meningitis,  peri- 
tonitis, and  intestinal  ulceration  (with  enlarged  mesenteric  glands)  as 
often  evidenced  by  obstinate  diarrhoea. 

The  following  case  shortly  illustrates,  both  in  its  history,  signs  and 
course,  the  form  of  phthisis  frequently  seen  in  young  children.  A  boy 
of  nearly  four  years  old  was  admitted  with  an  account  of  suffering  from 
sickness,  headache,  diarrhoea  and  noticeable  cough  for  a  few  weeks  pre- 
viously.    There  was  no  family  history  of  lung  or  other  disease ;  but  the 


ON  PHTHISIS  AND  MEDIASTINAL  GLAND  DISEASE.        393 

boy  had  never  been  well,  and  had  coughed  slightly  since  measles  followed 
by  whooping-cough  two  years  before.  At  first  scattered  rales  only  were 
heard  at  the  bases ;  but  later  on  some  dulness  and  rather  fine  crepitation 
were  discovered,  mainly  over  the  upper  half  of  both  lungs.  The  fingers 
were  clubbed ;  there  was  much  diarrhoea  and  night  sweating ;  and  the 
temperature  was  hectic  throughout,  varying  between  normal  and  about 
1030.  The  glands  in  the  neck  and  axilla  were  enlarged.  After  five 
months,  with  progressive  physical  signs,  cough  and  emaciation,  the  boy 
died,  having  developed  considerable  oedema  of  his  feet  and  a  small 
purpuric  eruption.  The  post-mortem  showed  extensive  caseous  tubercle, 
softening  into  small  cavities,  in  both  lungs ;  large  and  caseous  bronchial 
and  mesenteric  glands ;  tubercular  ulceration  of  intestine,  and  numerous 
small  tubercles  in  the  liver. 

With  regard  to  the  frequent  difficulty  in  diagnosis  of  the  acuter  forms 
of  phthisis  with  caseous  pneumonia  from  non-tubercular  broncho-pneu- 
monia, nothing  can  be  said  from  the  point  of  view  of  physical  signs  ; 
but  we  should  remember  that  an  acute  broncho-pneumonia  following  on 
measles,  especially  when  extensively  involving  both  lungs,  is  very  apt  to 
be  tubercular ;  and  we  may  be  further  aided  by  the  previous  and  family 
history  of  the  case.  In  tuberculosis,  especially  of  the  pulmonary  form 
occurring  in  children  beyond  infancy,  there  is  a  considerably  larger  pro- 
portion of  cases  with  a  marked  hereditary  history  of  phthisis  than  in 
infantile  tuberculosis  taken  as  a  whole.  The  presence  of  glandular  affec- 
tion or  other  evidence  of  struma  favours  the  diagnosis  of  tubercular  lung- 
disease  ;  and  I  think  that  it  is  especially  and  perhaps  only  in  pulmonary 
phthisis,  among  all  the  other  forms  of  tuberculosis,  that  the  so-called 
"  tubercular  appearance,"  with  fine  features  and  complexion,  good  stature 
and  slender  bones,  is  of  any  importance  as  showing  a  predisposition  to 
tubercular  disease.  In  practice  we  should  certainly  beware  of  giving 
any  diagnostic  weight  in  individual  cases  to  the  somewhat  vague  de- 
scriptions of  the  scrofulous,  tubercular  or  phthisical  "habits."  "We  must 
always  hesitate  long  before  pronouncing  any  case  of  apparent  lung- 
mischief  in  children  to  be  unquestionably  phthisical ;  and  should 
remember  that  not  only  broncho-pneumonic  consolidation  at  the  apices, 
but  also  pleural  thickening  and  empyema  localised  at  the  upper  part, 
may  closely  simulate  phthisis  as  regards  both  physical  signs  and  many 
symptoms.  In  all  doubtful  cases  the  exploratory  syringe  should  be  used  ; 
and  repeated  examination  should  be  made  of  the  sputum  for  bacilli, 
whenever  possible.  It  must  also  be  noted  that  physical  signs  of  excava- 
tion, quite  indistinguishable  from  those  heard  over  tubercular  cavities, 
may  often  be  found  over  one  or  more  regions  of  lungs  which  have  been 
the  subjects  of  prolonged  attacks  of  broncho-pneumonia.  These  signs  are 
due  to  marked  dilatation  of  the  bronchial  tubes,  which  in  some  degree  is 


394  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

usually  observed  in  fatal  cases ;  and  they  often  vanish  completely,  though 
gradually,  owing  to  the  contraction  of  the  tubes,  with  the  subsidence  of 
the  catarrhal  process  and  general  improvement  of  symptoms.  I  have 
over  and  over  again,  especially  in  past  years,  been  obliged  to  renounce  a 
too  hasty  diagnosis  of  phthisis  and  a  consequently  erroneous  prognosis,  in 
cases  of  pulmonary  mischief  in  young  children.  The  truth  impresses 
itself  on  me  more  and  more  that  at  least  in  childhood  and  in  the 
absence  of  proof  of  the  existence  of  tubercle  bacilli,  we  must  rely  for  a 
diagnosis  of  phthisis  much  more  on  the  symptoms  than  on  the  physical 
signs.  As  regards  the  symptoms,  with  the  exception  of.  the  point  already 
alluded  to,  they  are  identical  with  those  of  the  adult  disease. 

Under  the  general  heading  of  chronic  phthisis  I  shall  consider,  for 
practical  purposes,  the  very  mixed  class  of  cases  which  have,  as  points 
in  common  involving  chronicity,  both  fibrosis  of  lung,  of  varying  extent 
and  distribution,  and  a  tendency  to  more  or  less  symptomatic  quiescence, 
with  stationary  or  slowly  progressing  physical  signs.  In  this  class  we 
find  some  cases  where  a  tubercular  origin  cannot  be  questioned ;  others 
where  a  tubercular  connexion,  although  existent,  is  nevertheless  obscure 
in  its  nature ;  and  still  others  where  no  tubercular  relationship  at  all  can 
be  demonstrated.  In  all  chronic  cases  of  tubercular  disease  of  lung  there 
is  more  or  less  secondary  fibrosis  in  the  neighbourhood  of  those  deposits 
which  are  in  a  state  of  retrogression ;  and  thus  fibrosis  may  be  regarded 
as  a  process  of  repair  and  as  part  and  parcel  of  the  chronic,  retarded  or 
"  cured  "  cases  of  the  ordinary  phthisis  that  we  have  already  considered. 
Extensive  fibrosis,  in  cases  of  this  kind,  is  infrequent  in  childhood, 
owing  to  the  usually  more  rapid  course  of  the  disease  than  in  later 
life.  We  often,  however,  meet  with  cases  of  chronic  consolidation  of  the 
lungs,  and  more  especially  of  one  lung,  in  children  beyond  the  period  of 
infancy,  where  the  symptoms  and  physical  signs  are  of  insidious  origin 
and  slow  progress,  and  where  after  death,  which  is  usually  from  some 
intercurrent  attack  of  acute  disease  either  inflammatory  or  tubercular, 
extensive  induration  of  the  lung  is  found,  due  to  a  development  of 
nucleated  fibroid  tissue  in  the  interlobular  septa,  the  alveolar  walls  and 
the  bronchial  tubes,  and  leading  to  extensive  destruction  of  the  lung- 
cells.  In  some  of  these  cases  caseous  deposits  are  seen  in  the  lungs  or 
bronchial  glands  or  elsewhere ;  and  tubercular  cavities  are  sometimes 
found,  as  well  as  dilatation  of  the  bronchial  tubes,  which  in  some  degree 
accompanies  most  cases  of  chronic  fibrosis.  It  is  in  this  class  of  cases, 
where  some  evidence  of  tubercle  is  found  post-mortem  with  a  predomi- 
nant amount  of  fibroid  change,  that  the  difficulty  meets  us  as  to  whether 
we  should  regard  the  disease  as  primarily  tubercular  with  secondary 
fibrosis,  or  as  chronic  inflammation  of  the  lung,  or  pulmonary  "cirrhosis," 
arising  out  of  a  catarrh  and  subsequently  infected  by  tubercle.     There 


ON  PHTHISIS  AND  MEDIASTINAL  GLAND  DISEASE.        395 

is  no  doubt  that  in  some  instances,  after  a  long  course  of  more  or  less 
illness  marked  by  the  symptoms  presently  to  be  noticed  and  by  the 
signs  of  consolidation  limited  to  one  lung,  there  is  ultimately  evi- 
dence of  breaking  down  of  the  lung,  with  some  affection  of  the  other ; 
and  the  symptoms  of  ordinary  phthisis  supervene,  tubercle  bacilli  being 
found  in  the  sputum.  In  another  class,  however,  the  fibrotic  affection 
apparently  undergoes  little  change,  there  are  no  signs  or  symptoms  of 
softening,  and,  whether  the  disease  be  limited  entirely  to  one  lung,  as  it 
very  often  is,  or  involves  both  to  some  extent,  no  trace  of  tubercle  of 
whatever  kind  or  condition  is  found  post-mortem  in  the  cases  which  die 
from  the  intercurrent  attacks  of  bronchitis  or  broncho-pneumonia  to  which 
they  are  greatly  subject.  It  is  not  within  the  scope  of  these  remarks  to 
discuss  the  question  as  to  whether  all  fibrosis  of  the  lung  which  ends  in 
phthisis  is  primarily  tubercular ;  but  it  may  be  said  that,  as  far  as  this 
affection  as  found  in  children  is  concerned,  there  is  at  least  considerable 
clinical  evidence  of  some  tubercular  connexion  in  many  instances,  even 
when  apparently  one  lung  only  is  affected;  and,  further,  that  we  have 
no  practical  means  of  distinguishing  during  life  between  tubercular  and 
non-tubercular  cases.  We  are  on  firm  ground,  however,  in  stating  that 
extensive  pulmonary  fibrosis  in  children  arises  mainly  out  of  one  or 
several  attacks  of  broncho-pneumonia,  or  follows  on  chronic  bronchitis, 
often  with  intercurrent  acute  attacks ;  and  many  hold  that  it  may  result 
from  a  true  "lobar"  pneumonia  or  a  pleurisy.  Morbid  anatomy  favours 
the  view  that  the  inflammatory  process  begins  in  most  instances  in  the 
lung  itself,  invading  the  smallest  bronchial  tubes,  the  interlobular  septa, 
and  the  walls  of  the  air-cells.  According  to  the  stage  of  the  disease  the 
fibrosis  may  be  seen  in  the  form  of  streaks  of  various  sizes  intervening 
between  healthy  portions  of  lung,  or  involving  the  whole  of  a  lobe  or 
the  entire  lung.  In  many  cases  the  pleura  is  much  thickened  throughout, 
and  so  closely  adherent  that  the  lung  can  be  removed  only  by  cutting. 
There  has,  however,  in  my  own  experience  been  little  or  no  clinical 
evidence  or  suspicion  of  a  pleurisy  being  the  starting-point  of  pulmonary 
fibrosis  as  seen  in  children  ;  and  out  of  a  large  number  of  cases  of  pleurisy 
which  I  have  been  able  to  examine  long  after  the  attack  I  cannot  re- 
member a  single  case  of  this  form  of  chronic  lung-disease,  often  as  an 
apparently  simple  pleural  effusion  has  been  the  first  overt  sign  of  ordinary 
tubercular  phthisis. 

In  a  very  considerable  number  of  my  cases  with  the  signs  and  course 
of  extensive  fibroid  disease  of  lung  there  has  been  a  markedly  phthisical 
family  history,  a  fact  which  may  have  some  bearing  on  the  vexed 
question  of  the  possible  causal  part  played  by  a  tubercular  process  which 
may  have  become  obsolete  even  in  cases  with  no  evidence  of  tubercle 
post-mortem.     The  subjects  of  the  disease  are  mostly  children  beyond 


396  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

four  or  five  years  old  with,  as  a  rule,  a  history  of  frequent  chest  attacks 
not  seldom  dating  from  measles  or  pertussis,  and  gradually  increasing 
dyspnoea  on  exertion.  Cough  may  be  very  slight  at  first,  but  in  time 
is  usually  prominent,  with  much  expectoration  and  a  tendency  to  par- 
oxysmal attacks  closely  simulating  whooping-cough.  Emaciation  is  often 
slight  and  always  gradual,  and  in  some  instances,  where  the  disease 
seems  stationary,  the  child  may  be  in  fairly  good  condition.  In  propor- 
tion, however,  to  the  respiratory  difficulty  there  is  pallor  or  blueness  of 
the  face,  the  fingers  are  clubbed,  the  veins  of  the  upper  part  of  the  body 
are  full,  and  there  are  the  usual  signs  and  symptoms  of  a  dilated  and 
hypertrophied  right  heart. 

In  most  cases  in  childhood  the  physical  signs  of  disease  are  limited  to 
one  lung,  at  least  for  a  long  and  indefinite  period ;  the  so-called  cases  of 
"  fibroid  phthisis  "  with  signs  in  both  lungs,  arising  out  of  inhalation  of 
irritating  substances,  being  almost  confined  to  adults.  We  therefore  find, 
after  a  while,  contraction  of  one  side  of  the  chest  with  much  impaired 
movement  and  percussion  note,  and  the  heart  is  displaced  towards  the 
affected  side.  This  displacement  is  especially  notable  when  the  right 
lung  is  diseased,  the  heart  being  sometimes  found  beating  in  the  right 
axillary  region.  The  auscultatory  signs  vary  according  to  the  activity  of 
bronchial  catarrh  and  the  degree  of  bronchiectasis,  or  to  the  presence  of 
cavities  arising  from  ulceration  through  the  bronchial  tubes  or  from  the 
tubercular  processes  which  may  be  present.  There  may  be  all  combina- 
tions of  dry  and  moist  sounds,  from  a  slight  degree  up  to  well-marked 
signs  of  one  or  more  cavities.  The  sputum  varies  much  in  amount  and 
character ;  in  some  early  or  almost  stationary  cases  there  is  none,  or  it 
may  appear  only  during  intercurrent  attacks  of  bronchial  or  pulmonary 
catarrh  •  while  in  most,  where  bronchial  dilatation  is  established,  or  where 
there  are  excavations  in  the  lungs  either  from  bronchial  ulceration  or  a 
tubercular  process,  the  sputum  is  both  profuse  and  markedly  foetid. 
Pyrexia  is  often  absent  for  long  periods,  and  in  some  cases  for  an  indefi- 
nite time ;  but  in  many,  even  when  there  is  no  other  evidence  of  pro- 
gressive disease,  pyrexia  in  a  slight  degree  and  of  a  remittent  character  is 
observed.  When  indeed  pyrexia,  and  still  more  when  signs  of  excava- 
tion as  well,  are  noted,  accompanied  by  increased  wasting  and  cough,  the 
case  is  one  which  is  called  by  some  "  fibroid  phthisis,"  and  is  only  dis- 
tinguishable from  ordinary  phthisis  by  the  limitation  of  the  physical 
signs  to  one  lung.  In  some  of  these  cases  the  other  lung  may  then  show 
signs  of  apical  mischief,  and  the  disease  may  progress ;  while  in  others 
the  active  signs  may  disappear  and  the  disease  resume  a  chronic  and 
apyretic  condition.  A  practical  lesson  I  have  learnt,  from  studying  fib- 
roid disease  of  lung  in  children,  is  that  we  must  not  pronounce  a  positive 
prognosis,  or  exclude  the  possibility  of  ordinary  phthisical  events  and  a 


ON  PHTHISIS  AND  MEDIASTINAL  GLAND  DISEASE.       397 

fatal  issue,  on  the  ground  that  these  one-sided  cases  appear  to  arise  from 
a  chronic  pulmonary  inflammation  of  non-tubercular  origin. 

"Whatever  their  source  may  be,  and  although  evidence  of  tubercle  post, 
mortem,  as  we  have  seen,  is  sometimes  undoubtedly  absent,  death  from 
an  outbreak  of  tuberculosis  is  by  no  means  rare.  We  must,  however,  re- 
member that  there  are  many  cases  where  the  disease,  confined  to  one 
lung,  becomes  after  a  while  apparently  stationary,  and  the  patient  may 
live  for  several  years  with  somewhat  impaired  nutrition  and  breathing 
power  and  with  normal  temperature.  The  physical  signs  as  well  as 
the  symptoms  are  here  those  of  past,  rather  than  of  present,  mischief, 
consisting  often  of  contraction  of  one  side,  with  intense  dulness  and 
bronchophony  and  but  few,  if  any,  additional  morbid  sounds. 

The  two  following  cases  shortly  illustrate  this  interesting  form  of  lung 
disease. 

A  girl,  aet.  thirteen,  subject  to  attacks  of  "bronchitis"  since  the  age 
of  three  months  and  treated  at  Shadwell  Hospital  for  rickets  when  two 
years  old,  was  admitted  with  the  history  of  cough,  foetid  sputum  often 
tinged  with  blood,  and  general  weakness,  of  two  years'  duration.  Her 
mother,  father  and  several  brothers  and  sisters  suffered  from  chronic 
cough  ;  and  one  sister,  set.  eleven,  died  in  Guy's  Hospital  with  "  chronic 
bronchitis."  Several  near  relatives  had  died  of  consumption.  The 
patient  was  somewhat  thin,  with  a  fine  clear  skin  and  long  eyelashes. 
The  left  chest  was  markedly  contracted  and  dull  all  over ;  and  abundant 
extensive  crackling  was  heard,  with  loud  bronchophony  and  whispering 
pectoriloquy  near  the  angle  of  the  scapula.  There  were  no  abnormal 
signs  on  the  other  side  of  the  chest.  At  first  the  temperature  was  occa- 
sionally ioo°  in  the  evening,  but  soon  fell  to  normal.  The  girl  rapidly 
improved  with  ordinary  hygienic  treatment,  and  left  after  some  months 
in  apparently  good  health. 

(2.)  A  boy  of  three,  with  a  history  of  much  family  phthisis,  and  of 
"  bronchitis  "  when  a  baby,  but  of  good  health  since,  was  admitted  with 
cough,  wasting  and  night-sweating  of  six  months',  and  foetid  expectoration 
of  six  weeks',  duration.  He  was  thin,  with  bluish  complexion  ;  coughed 
spasmodically  ("  like  whooping-cough  "),  and  spat  profusely.  The  right 
chest  was  dull  all  over,  and  much  contracted  at  the  upper  part,  where  the 
breath  sounds  were  cavernous  and  attended  by  large  crepitation,  and  there 
was  distinct  cracked-pot  sound.  The  left  side  appeared  normal  to  exa- 
mination. During  six  weeks  in  hospital  the  child  improved  much,  and 
left  with  a  marked  gain  in  weight. 

The  two  subjoined  cases  are  inserted  to  exemplify  difficulties  often 
met  with  in  diagnosis  between  consolidation  of  the  lung  and  pleurisy. 
Of  the  first  it  may  be  questioned  of  which  kind  the  affection  originally 
was.     A  girl  of  seven  had  had  cough  all  her  life.     The  right  side  was 


39 8  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

contracted  and  dull  all  over,  and  the  breathing  for  the  most  part  was 
loudly  bronchial ;  but  there  were  no  added  sounds  of  any  kind,  and  the 
left  side  was  apparently  normal.  The  heart's  position  was  found  on  the 
right  side  of  the  sternum.  A  little  pus  was  seen  on  exploration  at  the 
angle  of  the  scapula,  but  none  on  four  subsequent  trials.  In  the  course  of 
some  weeks  coarse  metallic  rales  were  heard  over  a  large  area  on  the 
right  side,  and  slightly,  probably  from  conduction,  on  the  left.  There 
was  never  any  expectoration  or  fever.  It  was  thought  that  the  case  was 
one  of  fibroid  disease,  and  that  the  pus  might  have  come  from  a  dilated 
bronchus.  On  the  whole,  however,  considering  the  absence  of  expectora- 
tion, the  universality  of  the  dulness,  and  the  probably  normal  condition 
of  the  left  chest,  the  case  may  almost  equally  well  be  regarded  as 
pleuritic  in  its  entirety.  The  child  left  the  hospital  after  some  months 
in  the  same  state  as  on  admission. 

The  next  case,  in  a  child  one  year  old,  was  thought  at  first  to  be  pleural, 
but  proved  to  be  due  to  caseous  consolidation.  There  had  been  some 
cough  and  wasting  for  several  weeks,  but  the  breathing  was  not  much 
embarrassed  at  first.  Absolute  dulness  was  found  over  the  lower  half  of 
the  left  chest,  with  somewhat  bronchial  breathing  but  no  added  sounds. 
]STo  fluid  appeared  on  exploration  with  a  needle.  In  three  weeks  the 
child  died  with  increasing  debility  and  some  pyrexia,  but  with  no  change 
of  physical  signs.  The  left  lower  lobe  was  completely  adherent  to  the 
chest  wall  and  universally  caseous.  In  the  centre,  rather  towards  the 
base,  there  was  a  small  cavity  containing  creamy  fluid.  The  upper  lobe 
was  very  slightly  involved,  and  the  right  lung  was  distinctly  hyperaemic. 
The  mediastinal  glands  were  large  and  caseous,  the  mesenteric  glands 
much  swelled,  and  there  were  some  tubercles  on  the  surface  of  the  spleen. 
This  case  may  be  classed  with  those  referred  to  by  Dr.  Goodhart  under 
the  name  of  cheesy  solidification  of  the  lung. 

Treatment. — The  clinical  study  of  phthisis  in  children  teaches  us 
that,  comparatively  rapid  though  the  course  of  most  cases  may  be  towards 
the  usually  fatal  issue,  yet  there  is  reason  to  believe  that  arrest,  or  per- 
haps recovery,  occurs  somewhat  more  frequently  than  in  later  life.  There 
is,  moreover,  perhaps  some  indication  for  possibly  hopeful  treatment  in 
the  fact  that  it  is  especially  in  young  children  that  catarrhal  processes  in 
the  air-passages  so  often  seem  to  prepare  the  ground  for  the  entry  and 
development  of  the  tubercle  bacillus.  Besides,  therefore,  giving  all  atten- 
tion to  the  details  of  general  hygiene  and  nutrition,  which  are  of  the 
highest  importance  in  cases  of  suspected  or  demonstrated  phthisis  at  all 
ages,  we  must  ever  be  careful  to  protect  children  from  all  avoidable 
sources  of  catarrh.  The  good  effect  of  this  precaution  is  perhaps  best 
seen  in  cases  of  chronic  phthisis,  or  those  described  under  the  head  of 
fibroid  disease,  where  an  accession  of  catarrh  so  frequently  aggravates  the 


ON  PHTHISIS  AND  MEDIASTINAL  GLAND  DISEASE.        399 

disease,  and  where  residence  in  a  warm  climate  often  insures  quiescence 
of  symptoms  and  a  considerable  degree  of  health.  For  the  rest  there  is 
little  to  be  said  regarding  the  treatment  of  phthisis  in  children  as  dis- 
tinguished from  adults.  The  most  nutritive  diet  consistent  with  indivi- 
dual digestion  must  be  insisted  on,  including  abundance  of  cream ;  and 
cod-liver  oil  should  be  taken  as  persistently  as  possible.  In  early  cases 
the  hypophosphite  of  lime  or  soda  should  I  think  be  given  regularly 
and  for  long,  although  I  cannot  say  that  I  have  ever  seen  any  definite 
good  results  from  this  drug  in  the  well-established  disease. 

Arsenic  is  a  very  useful  drug  in  the  numerous  cases  with  an  element 
of  hope  in  them ;  as  also  is  iron,  which  I  have  no  reason  to  believe 
is  harmful  in  any,  although  stated  to  be  so  by  some  writers.  A  dry 
climate  is  to  be  insisted  on ;  but  whether  moderate  heat  or  cold  is  most 
suitable  will  entirely  depend  on  individual  cases.  The  best  climate  for 
any  case  is  that  which  renders  it  possible  for  the  child  to  have  plenty 
of  sunlight,  to  be  much  out  of  doors,  and  as  active  as  its  strength  permits. 
In  England  there  is  clearly  not  much  choice  of  winter  residences,  all  of 
which  are  unsatisfactory ;  but,  as  I  have  said  when  treating  of  struma, 
there  are  perhaps  no  better  spots  than  Bournemouth,  or  the  west  coast 
of  Wales.  Among  foreign  places,  many  of  which  are  highly  beneficial 
in  arresting  disease  by  affording  the  above-mentioned  conditions,  Egypt 
is  strongly  to  be  recommended,  and  all  the  more  since  accommodation 
is  now  provided  in  the  desert  close  to  the  pyramids,  and  thus  within  a 
short  distance  from  Cairo.  In  some  cases  a  sea-voyage  to  the  Cape 
or  Australia  is  of  great  use.  Failing  the  possibility  of  going  so  far, 
Arcachon,  Biarritz,  or  some  of  the  resorts  on  the  Riviera  may  be  tried. 
Patients  should  not  return  to  England  until  the  month  of  June,  and 
should  usually  leave  home  for  some  more  suitable  climate  not  later 
than  the  end  of  September.  In  the  summer  many  patients  do  as  well 
in  England  as  anywhere.  Both  the  numerous  watering-places  on  the 
East  coast,  and  the  Yorkshire  moors,  supply  favouring  conditions  in  the 
hot  months. 

In  advanced  cases  we  must  of  course  depend  on  the  usual  symptomatic 
treatment,  which  cannot  be  detailed  here.  We  shall  often  find  much 
benefit  from  frequently  repeated  small  doses  of  opium  which  check  cough 
and  allay  irritability ;  and  from  the  regular  and  sometimes  free  admini- 
stration of  alcohol,  either  as  wine  or  brandy.  Some  recommend, 
apparently  on  antiseptic  principles,  the  internal  use  of  creasote  in  doses 
of  one  or  two  drops  two  or  three  times  a  day  ;  and,  for  checking  diarrhoea, 
the  occasional  administration  of  two  to  four  grains  of  naphthol  or  naph- 
thalene, according  to  age.  These  latter  drugs  appear  to  be  of  use  in  some 
cases ;  but  my  experience  of  them,  as  yet  but  slight,  has  had  no  uniform 
result.     Their  nauseous  taste  is  difficult  to  conceal. 


400  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

I  would  add  that  in  the  class  of  cases  above-mentioned,  where  there 
may  be  doubt  whether  we  have  to  do  with  a  recoverable  broncho- 
pneumonia or  with  tubercular  disease,  and  in  many  of  which  the  signs 
and  symptoms  ultimately  disappear,  there  is  no  harm  but  possibly  good  to 
be  expected  from  the  early  and  repeated  use  of  vigorous  counter-irrita- 
tion to  the  affected  part  by  means  of  the  croton-oil  or  the  iodine  lini- 
ment. In  spite  of  the  absence  of  positive  evidence  of  benefit  therefrom,  I 
follow  and  recommend  this  now  somewhat  antiquated  line  of  treatment. 

I  omit  all  discussion  of  antiseptic  methods  of  treatment,  by  inhalation 
or  otherwise,  based  on  the  bacillary  origin  of  tuberculosis,  in  the  belief 
that,  however  practically  valuable  for  prophylaxis  and  public  hygiene 
our  recent  setiological  knowledge  may  well  prove  to  be,  it  has  as  yet 
had  no  influence  on  individual  therapeusis,  with  the  exception,  perhaps, 
of  the  lesson,  taught  by  the  infective  qualities  of  phthisical  sputum,  that 
we  should  protect  patients  from  the  possibly  additional  ill  effect  of  their 
own  discharges  by  directing  them  to  expectorate  only  into  vessels  pro- 
vided for  the  purpose  and  containing  some  germicide. 

Disease  of  Mediastinal  Glands. 

It  is  especially  the  tracheo-bronchial  glands,  so  often  the  subjects 
of  enlargement  and  caseation  in  childhood,  which  will  concern  us  here. 
Clinically  this  enlargement  of  the  glands,  if  excessive,  may  give  rise 
to  a  set  of  symptoms,  due  to  involvement  of  neighbouring  nerves 
and  organs,  which  justifies  separate  notice.  Similar  results  of  course 
may  follow,  and  with  much  greater  proportionate  frequency,  on  other 
and  rarer  forms  of  mediastinal  disease,  such  as  abscess  or  growths  of 
lymphomatous  or  sarcomatous  nature,  or  to  some  extent  on  the  chronic 
mediastinal  thickening  which  is  sometimes  met  with  in  connexion  with 
pericarditis.  It  must  be  remembered  that  the  bronchial  glands  are 
almost  always  enlarged  and  caseous  in  tubercular  lung-disease,  and  that 
we  but  rarely  meet  with  any  special  symptoms  due  to  their  enlarge- 
ment in  the  course  of  recognised  phthisis.  There  is,  however,  a  well- 
known  group  of  cases  where  enlargement  of  bronchial  glands,  with  or 
without  definite  symptoms,  precedes  the  pulmonary  mischief,  as  evi- 
denced by  post-mortem  examination  where  the  disease  is  seen  to  have 
started  at  the  root  of  the  lung.  In  most  cases,  including  this  latter  class, 
there  are  no  symptoms  or  physical  signs,  even  when  the  enlargement  of 
the  glands  is  found  post-mortem  to  be  considerable.  Of  this  I  have 
several  times  satisfied  myself.  In  others  there  may  be  symptoms  of 
pressure  on  the  pneumo-gastric  nerve,  such  as  hoarseness  or  spasmodic 
cough ;  oedema  of  the  face  and  upper  part  of  the  body,  due  to  pressure 
on  the  superior  cava  or  jugular  veins,  may  appear ;  or  infarcts  and  haemo- 


ON  PHTHISIS  AND  MEDIASTINAL  GLAND  DISEASE.        40  I 

ptysis  may  result  from  involvement  of  the  pulmonary  vessel?.  There 
may  also  be  stridulous  breathing  from  pressure  on  the  trachea.  Even 
when  many  of  these  symptoms  are  present,  it  is  often  impossible  to 
discover  any  special  physical  signs  by  percussion  or  auscultation  ;  but 
in  some  few  there  is  dulness  in  the  interscapular  space  with,  perhaps, 
tubular  or  bronchial  breathing  and  bronchophony,  and  in  others  more 
or  less  dulness  behind  the  upper  part  of  the  sternum  or  on  one  or  both 
sides  of  it  as  well,  with  or  without  similar  auscultatory  signs.  In  addi- 
tion to  these  signs  there  is  no  doubt  that,  listening  with  the  stethoscope 
placed  just  below  the  sternal  notch,  we  may  hear  from  time  to  time 
a  venous  hum,  produced  by  retraction  of  the  patient's  head  and  ceasing 
on  its  replacement.  From  observation  I  can  say  that  this  particular 
humming  sound  is  perhaps  very  frequent  in  cases  where  obvious 
pressure  signs  exist ;  that  it  is  very  often  absent  throughout  in  cases 
where  the  bronchial  glands  are  found  much  enlarged  post-mortem  ;  and 
that  it  is  not  seldom  heard  where  there  is  no  other  symptom  or  physical 
sign  of  bronchial  or  even  pulmonary  trouble  at  all.  In  the  absence, 
therefore,  of  signs  of  pressure  I  am  of  opinion  that  we  are  not  justified 
in  attributing  diagnostic  weight  to  this  phenomenon  as  an  early  sign  of 
bronchial-gland  disease.  Enlarged  tracheo-bronchial  glands  may  give 
rise  to  one-sided  signs  by  pressing  especially  on  one  bronchus,  and  causing 
impaired  resonance  and  diminished  breath  sounds,  or  marked  bronchial 
breathing.  They  may  also  break  down  into  an  abscess,  and  burst  into 
the  trachea  or  a  bronchial  tube.  On  the  other  hand  they  may  shrink 
and  become  calcified,  as  we  often  find  post-mortem  ;  but  in  all  probability 
this  result  is  confined  to  caseous  glands  which  are  neither  detectable  by 
examination  nor  evidenced  symptomatically. 


2    C 


SECTION    VI. 
DISORDERS  OF  THE  HEART  AND  CIRCULATION. 


SECTION  VI.— DISORDERS  OF  THE  HEART  AND 
CIRCULATION. 

Before  discussing  affections  of  the  heart  in  childhood,  which  may  be 
mainly  classed  under  the  heads  of  congenital  disease  and  inflammation 
of  the  heart  and  pericardium,  it  is  well  to  glance  at  those  anatomical 
and  physiological  peculiarities  of  the  circulatory  system  in  early  life 
which  have  a  bearing  both  on  the  physical  examination  of  the  organs 
concerned  and  on  certain  symptoms  of  their  derangement. 

The  apex  beat  in  infants  is  placed  further  outward  and  higher  up  than 
in  later  life,  being  generally  in  the  vertical  nipple  line  or  beyond,  and 
often  in  the  fourth  interspace.  The  usual  adult  position  of  the  apex 
beat  is  frequently  not  observed  until  the  child  is  three  or  four  years  old 
or  more,  when  the  width  of  the  heart  in  relation  to  the  chest  becomes 
less,  the  thorax  becomes  less  barrel-shaped,  and  the  diaphragm  takes  a 
lower  position.  The  apex  beat  is  also  more  diffused  in  early  childhood, 
and  the  sounds  are  shorter  in  relation  to  the  silences  and  sometimes 
reduplicated.  Owing  to  these  peculiarities  the  exact  localisation  of 
sounds  and  murmurs  is  often  somewhat  difficult.  Again,  the  ratio  of 
the  volume  of  the  heart  to  that  of  the  ascending  aorta  is  much  less  in 
early  than  in  adult  life,  being  only  about  one-fourth  greater  in  infancy, 
while  after  puberty  it  is  nearly  quintuple.  The  most  rapid  increase  of  the 
heart  takes  place  about  the  time  of  puberty  ;  and  it  follows  from  these 
facts  that  the  blood-pressure  is  much  less  in  childhood  than  afterwards, 
contributing  in  all  probability,  as  has  been  frequently  observed,  to  the 
tendency  to  take  cold  and  to  the  ready  failure  of  circulatory  power  so 
often  noticed  in  young  children,  and  well  exemplified  by  the  familiar 
chilblain.  Anomalous  and  temporary  murmurs  are  often  heard  over  the 
apparently  healthy  infant's  praecordium.  These  are  difficult  of  accurate 
explanation  and  are  probably  best  termed  hsemic. 

The  great  variability  of  the  pulse-rate  in  infants  and  young  children 
is  probably  accounted  for  by  the  imperfect  development  and  consequent 
instability  of  the  regulating  nervous  mechanism.  The  pulse-rate  at  birth 
generally  ranges  between  130  and  140,  and  may  be  higher,  sinking 
to  little  over  100  in  the  second  year,  and  only  very  gradually  reaching 
the  normal  of  75  to  So  about  the  time  of  puberty.  Very  slight  move- 
ments  and  mental   excitement  are   accompanied  by  great  rises   in   the 


406  DISORDERS  OF  THE  HEART  AND  CIRCULATION. 

pulse-rate ;  and  irregularity  of  force  and  rhythm,  often  observable  during 
the  first  year  while  the  child  is  at  rest,  is  easily  produced  and  much 
magnified  by  the  same  causes.  It  is  important  to  bear  in  mind  this  normal 
frequency,  irregularity  and  ready  excitability  of  the  healthy  infant's 
heart  when  looking  for  the  symptoms  of  any  disease  such  as,  for  instance, 
meningitis,  or  the  convulsive  state,  which  such  phenomena  often  indicate. 
The  younger  the  child  the  less  is  the  symptomatic  importance  of  irregu- 
larity of  pulse  alone.  After  the  first  year  or  two,  however,  this  irregu- 
larity is  often  of  the  greatest  diagnostic  weight  in  early  cerebral  disease 
and  some  other  affections.  In  a  case,  for  instance,  of  apparently  simple 
jaundice  of  about  three  weeks'  standing  in  a  healthy  child  of  six  years 
old,  marked  irregularity  of  pulse  was  one  of  the  earliest  symptoms  which 
ushered  in  the  delirium,  convulsions,  and  fatal  coma  of  what  proved  to 
be  acute  yellow  atrophy  of  the  liver. 

Disorder  of  the  heart's  working  may  occur  in  childhood,  as  in  adults, 
from  various  causes  other  than  anatomical  disease,  but  is  neither  of 
much  importance  nor  accompanied  by  that  distress  in  the  sphere  of 
feeling  which  so  often  fills  older  patients  with  dread.  Palpitation,  per- 
verted rhythm,  and  intermission  of  beats  are  not  rarely  observed ;  pain, 
but  seldom.  Such  irregularities  appear  to  be  connected  with  disorder 
of  the  stomach  and  bowels,  or  bad  nutrition  with  anaemia,  and  are  some- 
times marked  during  dentition.  I  have  seen  several  cases  which  seem 
to  correspond  closely  with  those  described  by  Da  Costa.  These  are 
marked  by  irregular  rhythm  and  infrequent  action  of  the  heart  without 
any  discoverable  condition  or  excitant  to  account  for  them.  Da  Gosta 
terms  such  cases  idiopathic,  and  states  that  they  mostly  begin  after  three 
years  of  age,  and  generally  last  till  puberty,  but  are  sometimes  permanent. 
He  notes  further  that  during  febrile  attacks  the  cardiac  rhythm  in  these 
cases  becomes  irregular.  I  am  inclined  to  attribute  these  phenomena  to 
disturbed  innervation,  which  is  usually  part  of  a  more  or  less  wide-spread 
nervous  disorder. 

Functional  disorder  of  the  heart  is  to  be  treated  by  attacking  the 
conditions  out  of  which  it  seems  to  arise,  and  the  avoidance  of  all 
demonstrably  exciting  causes.  The  diet  must  be  duly  regulated  when 
gastro-intestinal  symptoms  accompany  the  cardiac  trouble ;  and,  for  the 
rest,  we  should  strongly  advise  moderate  exercise,  mental  distraction,  and 
all  attainable  sun-light  and  fresh  air.  I  do  not  think  that  digitalis  or 
similarly  acting  drugs  are  of  any  avail;  but  the  nutritive  effects  of 
arsenic  and  iron  and,  in  some  cases,  cod-liver  oil  are  not  to  be  doubted 
and  are  sometimes  very  soon  observable,  especially  in  patients  who  are 
anaemic. 


CONGENITAL  HEART-DISEASE.  407 


CHAPTER  I. 

CONGENITAL    HEART-DISEASE. 

Cyanosis,  or  the  "  blue  disease,"  characterised  by  varying  degrees  of  purple 
discolouration  of  the  skin  and  mucous  membranes,  hurried  breathing,  sur- 
face coldness,  and  clubbing  of  the  fingers  and  toes,  is  usually  associated 
with  congenital  malformation  of  the  heart  or  large  vessels.  Cyanosis, 
however,  may  occur  without  heart-disease  as  the  result  of  long  standing 
pulmonary  affection,  such  as  extensive  emphysema  or  thick  fibrinous 
pleural  adhesions,  and,  in  moderate  degree,  in  ill-developed  children 
with  or  without  mental  deficiency.  Congenital  heart-disease  on  the 
other  hand,  marked  by  physical  signs  and  some  symptoms  of  disturbed 
circulation,  may  be  found  unattended  by  cyanosis. 

The  symptoms  of  cyanosis  in  connection  with  heart-disease  are  observed, 
in  about  two-thirds  of  all  cases,  either  at  birth  or  within  the  first  week. 
In  the  rest  they  arise  at  varying  intervals  after  birth,  sometimes  after 
many  years,  their  retarded  appearance  being  probably  due  to  extra  stress 
on  the  imperfect  heart,  associated  with  physical  exertion,  mental  excite- 
ment, the  onset  of  some  acute  disease,  or  anything  which  may  induce 
disturbance  of  compensation.  The  longer  the  interval  after  birth  when 
the  symptoms  appear,  the  more  often  a  definite  exciting  cause  can  be 
established.  The  depth  of  discolouration  varies  much  in  different  cases 
and  in  the  same  case  at  different  times,  some  patients  when  at  rest 
showing  almost  a  natural  colour,  while  in  others  the  nose,  cheeks,  lips, 
tongue,  fingers  and  toes  may  be  almost  black  and  the  whole  body  dark 
purple.  Excitement  always  deepens  this  colour  and  increases  the 
frequency  of  breathing. 

The  axillary  temperature  is  almost  always  below  the  normal,  and 
likewise  often,  though  by  no  means  always,  the  temperature  taken  in 
the  rectum.  The  body  surface  is  felt  to  be  markedly  cold,  especially 
at  the  extremities.  The  heart-beats  are  generally  hurried,  irregular  or 
intermittent,  the  breathing  is  frequent,  and  there  may  be  cough  and 
occasional  haemoptysis.  Bad  digestion  often,  and  haamatemesis  sometimes, 
occur  as  signs  of  congested  stomach,  and  from  time  to  time  there  may  be 
bleeding  from  the  gums,  nose  or  bowel.  Anasarca  is  but  rarely  seen, 
and  only  towards  the  end.  The  patients  are  as  a  rule  very  small, 
emotional  and  especially  fretful ;  they  are  subject  to  drowsiness ;  and 
their  intellectual  functions  are  often  torpid,  though  not  seldom  apparently 
unimpaired. 


408  DISORDERS  OF  THE  HEART  AND  CIRCULATION. 

Physical  examination  shows  frequent  malformation  of  the  thorax, 
pigeon-breasts  being  very  numerous,  as  evidenced  by  my  own  case-books 
and  the  more  extensive  collections  of  many  others  ;  and  in  most  instances 
there  are  the  signs  of  enlarged  heart  and  a  murmur  or  murmurs, 
generally  loud  and  systolic,  over  the  prsecordium.  It  is  almost  always 
impossible  to  pronounce  definitely  upon  the  exact  nature  of  the  cardiac 
malformation  which  underlies  the  signs  and  symptoms  of  cyanosis ;  for, 
apart  from  the  fact  that  malformation  of  various  kinds  may  exist  without 
physical  signs,  the  possible  lesions  are  so  numerous  and  multiform,  owing, 
among  other  causes,  to  the  varying  periods  of  foetal  existence  when  arrest 
of  development  takes  place,  that  most  attempts  at  diagnosis  must  be 
confessed  to  be  mere  guess-work  or  more  or  less  probable  inference  from 
averages  based  on  anatomical  records.  The  classification  and  explanation 
of  congenital  malformation  of  the  heart  are  of  great  anatomical  import- 
ance ;  but  in  this  clinical  work  I  must  content  myself  with  observing 
that  the  most  frequent  lesion  in  cases  with  cyanosis  is  narrowing  or 
complete  obstruction  of  the  pulmonary  artery  with  some  consequent 
communication  between  the  two  sides  of  the  heart,  a  pervious  ductus 
arteriosus  and  an  imperfect  ventricular  septum  having  been  more 
frequently  recorded  than  a  similar  auricular  defect,  or  than  a  patent 
foramen  ovale.  It  follows  from  this  that  most  of  the  cases  are  due  to 
faults  of  development  occurring  quite  early  in  foetal  life ;  for  the  ventri- 
cular septum  is  normally  complete  by  the  end  of  the  third  month.  For 
a  most  lucid  exposition  of  this  subject  I  would  refer  the  reader  to  a 
paper  by  Dr.  Sharkey  in  the  Lancet  (1880,  vol.  ii.),  while,  to  those  who 
would  further  pursue  the  study,  the  classical  work  of  Peacock  remains  of 
unrivalled  value. 

The  prognosis  in  cyanotic  cases  is  uniformly  bad.  Improvement 
scarcely  ever  occurs,  and  very  few  survive  to  middle  age,  one-third  of 
all  dying  in  the  first  year  and  two-thirds  in  the  first  decade.  Cerebral 
haemorrhage,  convulsions  and  coma  are  often  the  immediate  causes  of 
death ;  and  bronchial  catarrh  with  collapse  of  the  lungs  and  broncho- 
pneumonia is  a  frequently  fatal  event.  I  can  corroborate,  too,  from  my 
own  cases  the  modern  teaching  that  cyanotic  patients,  in  spite  of  the 
pathological  dictum  of  Rokitansky  to  the  contrary,  show  a  certain  ten- 
dency to  suffer  from  pulmonary  tuberculosis.  Among  other  illustrations 
of  this  in  my  case-books  there  is  recorded  an  instance  of  well-marked 
phthisis  in  a  cyanotic  of  thirteen  years  old. 

But  little  can  be  said  with  regard  to  the  conditions  which  cause  or 
favour  congenital  malformation  of  the  heart  and  large  vessels.  Some 
few  cases  are  referable  to  foetal  endocarditis,  especially  in  the  right  heart. 
Other  defects  of  development  sometimes  co-exist,  such  as  visceral  trans- 
position, anencephaly,  spina  bifida,  and  umbilical  hernia.      Such  cases 


CONGENITAL  HEART-DISEASE.  409 

are  doubtless  far  more  common  among  the  working  population  of  large 
towns,  where  bad  hygienic  conditions  largely  contribute  to  the  production 
of  ill-formed  children,  than  in  the  country  or  among  the  children  of  the 
well-to-do.  Of  this  Dr.  Lewis  Smith  of  New  York  gives  interesting 
evidence.  Nervous  disturbances  which  accompany  maternal  impressions 
may  be  reasonably  suspected,  though  perhaps  scarcely  proved,  to  be  causal 
in  many  instances.  There  seems  on  the  whole  to  be  a  slight  numerical 
predominance  of  male  cases,  as  is  the  fact  with  other  congenital  de- 
formities. 

The  cyanosis  itself  we  must,  with  Morgagni  and  Peacock,  regard  as 
the  result  of  long-continued  capillary  stasis  and  obstruction  at  the  centre 
of  circulation,  and  but  slightly,  if  at  all,  to  the  commingling  of  arterial 
and  venous  blood. 

Where  there  is  no  cyanosis,  congenital  disease  of  the  heart  may  always 
be  suspected  when,  with  or  without  marked  symptoms  of  disturbed 
circulation,  the  physical  signs  of  murmur  and  enlarged  heart  point  to 
stenosis  of  the  pulmonary  artery ;  as  also  in  cases  where  there  are  para- 
doxical sounds  and  signs  unattributable  to  rheumatism  or  other  affections 
known  to  be  productive  of  heart-disease.  We  often  meet  "with  such  cases 
at  any  age,  which  may  be  with  all  probability  credited  to  some  congenital 
defect,  and  where  the  frequent  absence  of  any  symptom  or  other  sign  of 
heart-disease  will  usually,  at  least  after  the  lapse  of  time,  completely 
justify  a  good  prognosis.  A  systolic  bruit,  and  nothing  more,  in  the 
region  of  the  pulmonary  artery  is  very  frequent  in  this  class  of  cases ; 
and  I  would  lay  stress  on  a  systolic  murmur,  heard  loudest  at  the  base  of 
the  heart,  and  very  clearly  over  the  back  of  the  chest,  as  often  indicating 
a  congenital  affection  which  is  symptomatically  unexpressed. 

The  treatment  of  patients  with  cyanosis  may  be  summed  up  under  the 
heads  of  continuous  warmth  to  the  body  (not  forgetting  the  nocturnal 
hot  bottle  to  the  feet),  digestible  diet,  stimulation  from  time  to  time  by 
alcohol,  and  rest  for  the  body  and  the  mind.  Digitalis  may  occasionally 
be  useful  in  cases  where  dropsy  may  have  set  in  and  when  the  heart- 
beats are  frequent  and  irregular.  Blood-letting  is  certainly  indicated, 
when  dyspnoea  is  urgent,  for  the  relief  of  the  probably  overloaded 
heart. 


4-IO  DISORDERS  OF  THE  HEART  AND  CIRCULATION. 


CHAPTER    II. 

CARDIAC    INFLAMMATION   AND   VALVE-DISEASE. 

Before  discussing  the  clinical  aspects  of  valve-disease  in  childhood,  and 
of  the  affections  usually  described  under  the  heads  of  endocarditis  and 
pericarditis,  it  is  practically  important  to  consider  the  part  played  by 
involvement  of  the  muscular  substance  of  the  heart  itself.  Now,  although 
localised  abscess  or  diffused  myocarditis,  readily  recognised  post-mortem 
and  sometimes  leading  to  cardiac  aneurysm,  may  occur  in  childhood  more 
often  than  in  later  life  either  as  the  result  of  pyaemia  in  connexion  with 
bone-mischief  or  of  endo-  or  peri-carditis  or  other  causes,  it  is  nevertheless 
very  rare  and  need  not  be  dwelt  on  except  in  a  monograph  or  large 
systematic  work.  Its  proper  symptoms  are  those  of  rapid  heart  failure, 
lessening  or  absence  of  the  first  sound,  smallness  and  irregularity  of  pulse, 
difficult  breathing,  pallor,  palpitation,  and  often  praecordial  pain ;  and 
acute  cardiac  dilatation  may  be  evidenced  by  percussion.  When  it 
occurs  in  association  with  endo-  or  peri-carditis,  as  it  occasionally  does 
in  severe  rheumatism,  the  physical  signs  of  these  affections  are  of  course 
predominant ;  and,  generally  speaking,  its  existence,  from  whatever  cause 
arising,  is  rather  to  be  inferred  from  the  observation  of  excessive  heart 
failure  in  the  light  of  pathological  knowledge,  than  directly  demonstrated 
by  physical  examination. 

It  is  mostly  in  its  less  recognised  and  less  severe  forms  in  connexion 
with  rheumatic  heart-disease  that  myocarditis  becomes  of  great  clinical 
importance.  There  is  probably  some  involvement  of  the  underlying 
muscle  in  every  well-marked  case  of  recent  endo-  or  peri-carditis,  and 
this  condition  of  the  heart,  with  its  necessarily  impaired  function,  should 
be  prominently  before  us  in  the  mental  picture  we  form  of  any  acute 
case  of  heart-disease.  In  spite  indeed  of  the  probably  almost  constant 
primary  lesion  of  the  endocardium  in  rheumatic  heart- affection,  our 
clinical  conception  of  endo-carditis,  with  the  exception  of  its  ulcerative 
form  which  has  its  own  special  symptoms  and  dangers,  should  be  mainly 
that  of  its  causal  relationship  to  mechanical  valve  lesions  and  their 
chronic  effects  on  cardiac  structure  and  function.  Wherefore,  when  we 
think  of  acute  rheumatic  endocarditis  or  pericarditis  with  marked  cardiac 
disturbance,  we  must  never  forget  the  deeper  affection  of  the  heart  itself 
which  neither  murmur  nor  friction  sound  can  reveal  or  explain  ;  and, 
when  we  meet  with  the  not  very  rare  cases  where  in  acute  rheumatism 
there  are  continued  symptoms  and  signs  of  heart-trouble  with  no  physical 


CARDIAC  INFLAMMATION  AND  VALVE-DISEASE.  4  I  I 

signs  of  valvular  or  even  of  pericardial  mischief,  then,  by  keeping  a  pro- 
bable myocarditis  before  our  eyes,  we  shall  avoid  the  common  but  grave 
error  of  treating  them  lightly  because  there  is  "  no  murmur."  In  close 
association  with  this  matter  we  must  remember  the  numerous  cases  of 
heart-failure  in  children,  as  well  as  in  adults,  which  are  referable  to  more 
or  less  acute  dilatation  and  weakness  of  the  muscle  either  from  inflam- 
mation or  degeneration,  of  which  the  most  familiar  examples  are  seen  in 
the  course  or  sequel  of  acute  specific  diseases  such  as  diphtheria,  enteric 
fever,  scarlatina  and  several  others.  Fatty  degeneration  of  the  heart  at 
least  often  co-exists  with  or  follows  on  these  infective  conditions,  and  the 
symptoms,  generally,  are  those  of  more  or  less  dilatation,  with  difficult 
breathing,  failing  circulation  or  rapid  collapse.  There  may  or  may  not 
be  a  soft  blowing  murmur  at  the  apex ;  but  there  is  always  a  feeble  or 
absent  first  sound,  and  percussion  often  gives  evidence  of  enlarged  cavities. 

Bearing  in  mind  the  above  remarks  we  can  now  proceed  to  the  con- 
sideration of  endocarditis  and  valve-disease  in  childhood. 

Endocarditis  in  fcetal  life  is  often  connected  with  some  developmental 
defect,  and  attacks  the  right  heart  especially  though  not  exclusively,  the 
greater  liability  of  the  right  heart  being  doubtless  due  to  the  much 
greater  circulatory  stress  sustained  by  its  valves.  Union  of  the  segments, 
both  of  the  auriculo-ventricular  and  semilunar  valves,  is  frequent.  The 
chief  interest  attaching  to  these  conditions  is  the  probable  explanation 
afforded  thereby  of  certain  otherwise  inexplicable  cases  of  heart-disease. 
The  causes  of  foetal  endocarditis  are  obscure ;  rheumatism  may  possibly 
be  one ;  and  it  has  been  suggested  that  some  cases  are  due  to  absorption 
from  hsemorrhagic  foci  in  the  placenta. 

Endocarditis  from  rheumatism  is  still  more  frequent  in  childhood  than 
in  later  life.  A  larger  proportion,  too,  of  valve-diseases,  in  every  way 
comparable  to  demonstrably  rheumatic  cases,  is  at  first  sight  less  clearly 
attributable  to  rheumatism  in  young  children  than  in  adults ;  and,  if  the 
occurrence  of  marked  arthritis  were  regarded  as  necessary  for  the  diag- 
nosis of  rheumatism,  this  difference  would  be  of  considerable  importance. 
I  have,  however,  dealt  with  this  matter  in  sufficient  detail  under  the 
heading  of  rheumatism,  and  will  only  say  here  that  endocarditis  in  child- 
hood, as  evidenced  by  valve  disease,  is  rheumatic  in  a  vast  majority  of 
cases.  Of  98  instances  taken  consecutively  from  my  ward-books  I  find 
77  are  attributable  to  rheumatism,  either  from  definite  history  or  highly 
probable  inference.  Of  the  remaining  21,  some  may  be  almost  certainly 
referred  to  scarlatina  or  measles,  the  origin  of  the  others  being  obscure. 
There  are,  however,  no  grounds  for  believing  in  idiopathic  endocarditis ; 
and  we  must  remember  that  enteric  fever,  small-pox  and  other  septic 
disorders  may  all  be  credited  with  some  cases,  as  also  may  undiscovered 
rheumatism. 


4  I  2  DISORDERS  OF  THE  HEART  AND  CIRCULATION- 

Eespecting  the  relative  frequency  of  the  different  valve  affections,  these 
98  cases  show  that  under  the  rheumatic  heading  there  was  clinical  evidence 
of  mitral  regurgitation  alone  in  39,  of  mitral  stenosis  and  regurgitation 
in  25,  of  mitral  and  aortic  disease  in  7,  of  mitral  stenosis  alone  in  4,  of 
tricuspid  and  mitral  stenosis  in  1,  and  of  tricuspid  disease  alone  in  1, 
the  last  case,  set.  12,  with  a  history  of  perfect  health  in  early  years  be- 
fore rheumatism,  being  examined  post-mortem  and  showing  normal  mitral 
and  aortic  valves.  I  would  here,  however,  remark,  from  my  experience 
of  necropsies  generally,  that  tricuspid  valvulitis  from  rheumatism  is  much 
more  frequent  than  is  usually  taught ;  and  would  refer  to  the  publication 
by  Dr.  Hebb1  of  14  cases  observed  during  four  years  in  the  post-mortem 
room  of  Westminster  Hospital. 

Of  the  21  cases,  where  no  probable  rheumatism  could  be  established, 
10  had  double  mitral  murmurs,  7  a  systolic  apex  murmur  only,  and  4  a 
prsesystolic  murmur  only.  I  can  find  no  record  in  the  above-mentioned 
list  or  among  many  other  instances  of  heart-affection  registered  under  the 
headings  of  rheumatism  and  chorea — amounting  to  260  in  all — of  a 
single  case  of  aortic  valve-disease  with  unaffected  mitral,  nor  of  any 
aortic  case  which  was  not  clearly  of  rheumatic  origin.  In  one  instance, 
however,  which  was  under  my  observation  very  frequently  during  eight 
years,  a  double  aortic  murmur  only  was  heard  during  life,  though  the 
necropsy  demonstrated  marked  disease  of  the  mitral  valve  as  well.  This 
negative  observation  illustrates  well  the  clinical  truth  that  aortic  valve- 
disease  by  itself  is  not  connected  at  any  age  with  rheumatism  or  the 
ordinary  causes  of  endocarditis,  but  is  rather  an  affection  arising  out  of 
vascular  disease  or  strain  in  adult  life.  Mitral  stenosis  alone  seems  to 
be  especially  connected  with  the  less  marked  forms  of  rheumatism,  and 
is  conspicuous  among  valve  affections  of  uncertain  origin.  It  is  also 
specially  likely  to  cause  embolism,  cerebral  and  otherwise. 

Valve-disease,  notably  of  the  rheumatic  kind,  seems  to  be  rare  in 
children  under  six,  and  to  become  prominent  at  about  the  same  age  as 
when  articular  rheumatism  is  usually  first  observable.  Out  of  150  cases 
of  definite  valve-disease,  registered  either  as  such  or  under  the  head  of 
rheumatism,  only  six  were  under  this  age,  ranging  from  3  to  5^  years  old ; 
and  the  youngest  one  was  in  all  probability  not  rheumatic.  It  is  at  least 
certain  that  signs  and  symptoms  of  valve-disease  are  but  seldom  shown 
under  the  age  of  six.  On  the  whole,  however,  children  are  far  more 
liable  to  endocarditis  than  adults,  and  most  cases  of  rheumatic  heart- 
disease  arise  in  the  early  stage  of  the  earlier  attacks  of  rheumatism.  Few 
persons  suffer  from  the  fever  for  the  first  time  after  35  years  old,  and 
rheumatic  subjects  who  escape  heart-disease  in  early  life  have  a  fair 
chance  of  subsequent  immunity. 

1  See  vol.  iv.  of  the  Westminster  Hospital  Reports  (Churchill). 


CARDIAC  INFLAMMATION  AND  VALVP]-DISEASE.         4  I  3 

Ulcerative  endocarditis  is  not  frequent  in  childhood,  and  has  no  clinical 
peculiarity  at  this  period.  I  have  seen  hut  three  probable  cases  in  children, 
which  were  suspected  during  life,  one  only  having  been  submitted  to  post- 
mortem examination,  which  alone  gives  positive  evidence  of  this  disease. 
Ulcerative  endocarditis  is  sometimes  found  post-mortem,  as  often  in  adults, 
where  it  has  not  been  suspected ;  but  it  is  still  more  often  suspected 
where  it  is  not  found.  It  is,  however,  of  great  importance  to  bear  in 
mind  the  most  probable  signs  of  this  affection,  with  its  often  markedly 
intermittent  pyrexia  and  its  tendency  to  cause  emboli  in  various  parts. 
It  may  exist  with  few  or  no  prominent  symptoms  referable  directly  to 
the  heart,  and  may  closely  simulate  the  febrile  condition  of  some  forms 
of  ague  or  of  retained  collections  of  pus  in  various  parts  of  the  body. 

The  phenomenon  of  fibrous  nodules  in  acute  rheumatism  as  described 
under  that  heading  has  a  bearing  on  the  subject  of  heart-disease  ;  for  it  is 
rarely,  if  ever,  unattended  by  valve-mischief  of  a  usually  progressive  char- 
acter, and,  as  shown  by  Dr.  Coutts  and  others,  is  frequently  synchron- 
ous in  appearance  with  fresh  attacks  of  endocarditis.  It  is  true  that 
these  nodules  are  almost  always  accompanied  by  evidence  of  arthritis  ; 
but  it  would  appear  that,  in  the  absence  of  such  evidence,  nodules  are  a 
very  strong  indication  of  rheumatic  heart-disease,  and  should  give  rise  to 
at  least  a  very  guarded  prognosis  even  in  cases  apparently  not  otherwise 
severe.  Large  nodules  are  of  especially  bad  augury  according  to  Dr. 
Cheadle,  who  urges  the  microscopical  similarity  of  the  process  of  forma- 
tion of  nodules  and  of  valvular  vegetations. 

The  symptoms  of  extensive  valve- disease  in  childhood  are  much  the 
same  as  in  adults ;  but,  owing  probably  to  more  ready  and  complete  estab- 
lishment of  compensation  in  children,  we  more  often  find  the  symptoms 
very  slight.  It  is  remarkable  how  often,  especially  in  cases  of  well- 
marked  mitral  disease  with  enlarged  heart,  both  dyspnoea  and  dropsy  are 
conspicuously  absent,  even  under  the  stress  of  considerable  exertion.  On 
the  other  hand,  probably  a  large  majority  of  children  with  valve-disease 
quickly  deteriorate  and  die  as  the  age  of  puberty,  with  its  greater  heart- 
stress,  is  approached  or  reached.  I  have  seen  many  examples  of  this  ap- 
parently rapid  failure  of  compensation ;  and,  although  we  not  seldom  see 
quite  elderly  persons  with  valve-disease  dating  from  rheumatism  in  early 
youth,  the  cases  dating  from  early  childhood  are,  I  think,  but  few. 

The  proportion  of  cases  of  rheumatic  valve-disease  in  which  the  aortic 
valve  is  involved  is  considerably  less,  according  to  my  experience,  in  child- 
hood than  in  later  life.  It  must  be  also  remarked  that  children  with 
mitral  disease  are  especially  liable  to  become  thin,  and  are  usually  pale, 
this  peculiarity  being  probably  explicable  by  the  general  effect  of  deficient 
circulation  on  the  nutrition  at  a  period  when  the  body's  wants  are  great ; 
while  in  the  adult,  with  less  perfect  compensation,  the  mechanical  results 


414  DISORDERS  OF  THE  HEART  AND  CIRCULATION. 

of  the  valvular  failure  are  more  prominent,  and  are  evinced  in  the  face 
by  capillary  congestion. 

The  symptoms  of  the  onset  of  valve-inflammation  in  childhood  are 
often,  like  other  rheumatic  symptoms,  but  slight,  or  may  be  altogether 
absent,  the  condition  being  recognised  only  by  the  discovery  of  the  mur- 
mur ;  and,  even  when  the  primary  rheumatic  affection  has  been  well 
marked,  both  definite  murmur  and  symptomatic  evidence  of  the  valvulitis 
are  often  long  delayed.  The  heart,  therefore,  should  be  carefully  and  re- 
peatedly examined  in  all  rheumatic  cases  and,  indeed,  in  all  febrile  attacks 
of  doubtful  nature.  If  no  murmur  be  heard,  altered  sounds  and  actions 
may  attract  the  attention  of  the  experienced  observer  and  materially  in- 
fluence the  treatment  and  subsequent  course  of  the  case. 

It  must,  however,  be  remembered  that  the  beginning  of  acute  endo- 
carditis is  often  accompanied  by  other  signs  and  symptoms  probably 
referable  to  involvement  of  the  heart-muscle  and  pericardium.  Such 
are  preecordial  and  epigastric  pain,  signs  of  dry  or  liquid  pericardial 
effusion,  or  bulging  of  the  heart  region,  without  evidence  of  noteworthy 
pericardial  effusion,  owing  to  the  involvement  of  the  myocardium  with 
swelling  of  the  heart  from  distension  of  its  cavities. 

Among  other  modifications  of  the  heart-sounds,  which  may  point  to 
the  beginning  of  valve-disease  in  childhood,  I  may  mention  two.  The 
first,  especially  described  by  Dr.  Cheadle,  consisting  of  a  doubled  second 
sound  at  the  apex,  with  or  without  a  diastolic  murmur,  seems  to  be  an 
early  sign  of  mitral  stenosis.  These  phenomena  are  referred  by  him 
to  asynchronous  flapping  back  of  the  mitral  and  tricuspid  valves  and, 
when  the  diastolic  murmur  is  heard,  incomplete  falling  back  of  the 
mitral  after  systolic  closure.  The  second,  also  a  herald  of  established 
mitral  stenosis,  is  according  to  my  experience  very  much  more  often 
observable,  being  a  slightly  divided  first  sound  which,  after  exertion,  is 
frequently  accompanied  by  a  thrill,  and  at  once  develops  into  a  well- 
marked  murmur,  immediately  preceding  and  abruptly  ending  with  the 
heart's  impulse,  and  usually  described  as  "  praesystolic." 

I  have  several  times  observed  the  complete  disappearance  of  murmurs, 
in  all  probability  organic,  which  have  arisen  in  acute  rheumatism.  In 
four  cases  out  of  the  above-quoted  list,  besides  several  others  that  I 
have  seen,  well-marked  mitral  murmurs,  some  of  them  being  distinctly 
"  praesystolic  "  with  thrill,  disappeared  soon  after  the  fever,  no  signs  or 
symptoms  of  heart-disease  being  detected  on  examination  at  periods 
varying  from  two  to  three  months  afterwards.  Many  instances,  how- 
ever, of  vanishing  systolic  murmurs  at  the  apex  are  probably  not  due 
to  valvulitis  but  to  a  dynamic  cause  from  ventricular  dilatation. 

~No  instance  of  disappearance  of  a  definite  aortic  regurgitant  murmur 
has  hitherto  occurred  in  my  experience.     Here  must  be  remembered  the 


CARDIAC  INFLAMMATION  AND   VALVK   DISEASE.  4  I  5 

frequent  difficulty  of  distinguishing  between  early  double  aortic  murmur, 
before  consecutive  heart  enlargement  sets  in,  and  pericardial  sounds  of 
soft  and  indefinite  character ;  as  well  as  the  possible  confusion  of  some 
double  mitral  murmurs  with  pericarditic  friction.  Examples  of  such 
mistakes  by  experienced  auscultators  are  from  time  to  time  revealed  on 
the  post-mortem  table. 

In  two  cases  of  well-marked  rheumatic  mitral  disease  with  a  loud 
venous  humming  sound  in  the  neck,  a  double  murmur  at  the  base,  exactly 
simulating  that  of  aortic  valve  disease,  was  constantly  heard ;  but  both 
the  humming  and  the  pseudo-aortic  sounds  vanished  completely  during 
pressure  on  the  cervical  veins.  Lastly  I  would  record  a  remarkable 
case,  in  a  child  of  eight,  where  a  loud  and  long  diastolic  murmur,  as 
well  as  a  systolic  one,  was  always  heard  at  the  apex ;  but  the  necropsy 
showed  a  mitral  orifice  of  fully  three  inches  round,  and  no  lesion  other 
than  a  few  small  granulations  on  the  auricular  surface.  Such  a  diastolic 
murmur,  as  is  well  known,  is  usually  associated  with  marked  mitral 
stenosis. 

As  regards  prognosis  in  the  valvular  diseases  of  childhood  we  must 
remember,  in  addition  to  the  early  compensation  and  the  frequent  failure 
at  puberty,  the  common  occurrence  of  repeated  attacks  of  endocarditis 
and  pericarditis.  For  the  rest,  it  is  especially  true  in  childhood  that 
the  forecast  is  essentially  relative  to  the  individual  case,  and  necessitates 
careful  and  repeated  study  of  signs  and  symptoms.  Many  cases,  severe 
at  the  outset,  make  ultimately  good  progress;  while  others,  seemingly 
slight,  become  rapidly  worse  with  more  or  less  acute  dilatation  of  the 
heart. 

The  treatment  of  heart-disease  respects,  first,  the  early  acute  disorder 
or  those  affections,  especially  rheumatism,  out  of  which  such  disorder 
arises ;  and,  second,  established  cases  of  valvular  mischief. 

In  acute  cases  of  cardiac  inflammation,  whether  demonstrated  or  only 
suspected,  absolute  rest  and  freedom  from  excitement  are  of  the  first 
importance.  All  children  with  rheumatism  of  any  degree  should  be  kept 
strictly  recumbent.  When  the  onset  of  cardiac  or  exo-cardiac  mischief 
is  suspected  or  demonstrated  by  signs  or  sjmiptoms,  the  salicylates  or 
salicin  which  may  have  been  ordered  should,  as  a  rule,  be  discontinued 
at  once  ;  but,  if  the  heart  be  working  well  with  neither  over-frequent  nor 
irregular  rhythm,  these  drugs  may  be  carefully  persisted  with  in  severe 
articular  cases,  even  when  a  murmur  is  present.  There  is  no  doubt 
in  my  mind  that  both  these  medicines  depress  the  heart's  action  and 
neither  prevent  nor  arrest  endocarditis.  Acute  cardiac  trouble  and  all 
cases  marked  by  precordial  pain  are  very  frequently  much  relieved  by 
opium,  which  I  very  often  give  both  for  its  anodyne  and  probably  anti- 
inflammatory effects,  when  it  is  not  contra-indicated  by  marked  pulmonary 


41 6  DISORDERS  OF  THE  HEART  AND  CIRCULATION. 

complication,  and  am  inclined  to  regard  as  an  invaluable  remedy.  In 
most  cases  where  the  temperature  is  high,  and  especially  where  ulcera- 
tive endocarditis  is  suspected,  quinine  in  full  doses  should  be  given ; 
antipyrin,  in  my  opinion,  never.  Alcohol  is,  I  think,  always  strongly 
indicated  by  symptoms  of  cardiac  failure ;  and,  with  a  pulse  at  once 
irregular  and  frequent,  but  usually  not  otherwise,  digitalis.  I  say 
nothing  special  of  strophanthus  or  convallaria,  which  I  seldom  use  now ; 
for  I  have  found  that  the  sickness  which  digitalis  is  often  accused  of 
causing  is  very  rare,  if  not  mythical.  Such  apparent  sickness  can  often 
be  stayed  by  changing  the  vehicle  in  which  the  drug  is  given. 

In  chronic  heart-disease  absolute  rest  is  often  needful ;  but,  when 
marked  dyspnoea  and  dropsy  are  absent  and  there  are  no  signs  of 
pulmonary  oedema,  the  patient  may  be  allowed  moderate,  though  never 
competitive,  exercise,  and  should  enjoy  as  much  light  and  fresh  air  as 
possible.  The  body-warmth  should  be  sedulously  attended  to  and  a 
hot  foot-bottle  always  used  in  bed  during  cold  weather.  To  promote 
compensation  and  general  nutrition,  ample  but  easily  digestible  diet 
should  be  ordered,  with  appropriate  modifications  on  the  appearance  of 
the  gastric  symptoms  not  uncommon  in  mitral  and  right  heart-affections. 
Iron,  arsenic,  and  cod-liver  oil  are  valuable  aids  to  nutrition.  Hurried 
breathing  and  oedema  of  the  feet  with  a  frequent  and  irregular  pulse 
necessitate  digitalis.  If  diuretics  or  diaphoretics  be  indicated  by  in- 
creasing dropsy  I  prefer  a  hot-air  bath  (its  effects  being  carefully  watched), 
to  the  many  nearly  inert  drugs  of  this  class  and  to  the  active,  but  always 
depressing  and  sometimes  dangerous,  pilocarpine. 

With  regard  to  those  cases  where,  although  mitral  affection  co-exists, 
aortic  valve  incompetence  seems  to  be  the  prevailing  mischief,  as  evi- 
denced by  predominant  enlargement  of  the  left  heart,  marked  anaemia, 
recurrent  headaches,  a  tendency  to  syncope,  or,  more  often,  by  the  absence 
of  symptoms  of  mitral  failure  and  of  right  heart  distension,  I  would 
say  that  the  prognosis  in  childhood  is  comparatively  good,  especially,  of 
course,  in  the  latter  class  of  cases ;  and,  as  in  adult  life  the  subjects  of 
aortic  regurgitation  with  good  compensatory  hypertrophy  can  often  endure 
even  many  years  of  strenuous  labour,  so,  in  childhood,  moderate  exercise 
may  not  only  be  permitted  but  also  distinctly  recommended. 


PERICARDITIS.  417 


CHAPTER    III. 

PERICARDITIS. 

The  chief  clinical  interest  of  pericarditis  in  children  centres  round  the 
rheumatic  cases,  which  are  in  a  very  large  majority,  whether  evidenced 
by  extensive  signs  and  symptoms  or  only  by  a  localised  friction  sound. 
Pericarditis  detectable  during  life  is  not  indeed  so  overwhelmingly 
frequent  as  endocarditis  in  rheumatic  children,  physical  signs  of  the 
latter  occurring  in  more  than  80  per  cent.,  and  of  the  former  in  rather 
less  than  half,  of  my  cases  of  rheumatism.  It  is,  however,  frequently 
demonstrated  post-mortem  although  clinically  undiscovered ;  and  is  rarely, 
if  ever,  absent  in  fatal  cases  of  rheumatic  heart-disease.  Whether  or  no 
pericarditis  in  some  degree  always  accompanies  endocarditis  in  rheumatic 
children,  as  set  forth  by  Dr.  Sturges  in  a  most  important  lecture  on  "  The 
Rheumatic  Carditis  of  Childhood,"1  my  own  cases  amply  testify  that, 
whenever  it  does  occur,  endocarditis  is  present. 

Liquid  effusion  into  the  pericardium  is,  relatively  to  the  form  marked 
only  by  friction  sounds  throughout  with  but  slight  extension  of  precor- 
dial dulness,  much  more  frequent  in  children  than  in  adults ;  a  large 
majority  of  cases  at  first  characterised  by  friction  sounds  soon  showing 
evidence  of  distended  pericardium.  As  regards  symptoms  there  is  but 
little  special  to  our  subject,  the  dyspnoea,  pain  and  distress  being  gener- 
ally proportionate,  as  in  adults,  to  the  amount  and  rapidity  of  progress 
of  the  effusion.  "With  the  generally  more  rapid  progress  in  children  the 
initial  symptoms  are  often  well  marked  and  severe ;  and  epigastric  pain 
may  be  prominent.  Many  children,  however,  very  soon  accommodate 
themselves  to  even  a  large  effusion ;  and  I  have  seen  some  cases,  quite 
unparalleled  in  my  experience  of  adults,  where  the  patients  were  able  to 
walk  quickly  or  even  run  with  no  apparent  distress.  • 

In  many  cases,  especially  of  the  rheumatic  kind,  slight  signs  of  peri- 
carditis without  marked  cardiac  symptoms  may  be  very  early  accompanied 
by  a  rise  of  temperature.  Bearing  this  in  mind,  as  well  as  the  constantly 
associated  endocarditis  which  may  not  be  apparent,  and  the  frequent 
slightness  of  arthritic  symptoms  in  childhood,  we  should  at  once  examine 
the  heart-region  for  friction  or  other  abnormal  signs  in  all  cases  of 
pyrexia ;  avoiding  by  this  precaution  many  discreditable  blunders. 

Rheumatic  pericarditis  as  well  as  endocarditis  in  children  not  seldom 

1  See  Lancet,  August  27,  1892. 

2  D 


4  I  8  DISORDERS  OF  THE  HEART  AND  CIRCULATION. 

appears  to  pass  off  rapidly  and  entirely,  well-marked  signs  clearing  off 
with  no  remaining  evidence  of  either  adhesion  or  of  impaired  working 
of  the  heart.  When,  however,  heart-symptoms  continue,  unaccompanied, 
it  may  be,  by  abnormal  sounds  or  even  by  marked  increase  of  cardiac 
dulness,  pericardial  adhesion,  often  the  result  of  repeated  slight  attacks 
of  inflammation,  should  always  be  suspected.  Such  suspicions  are 
certainly  justified  by  the  presence  of  retraction  of  the  preecordial  region 
during  systole,  indicating  adhesion  of  the  pericardium  and  the  pleura. 

Other  than  rheumatic  causes  of  pericarditis  are  somewhat  more  fre- 
quent in  children  than  in  adults.  Such  are  septic  infection  in  the 
new-born,  from  phlebitis  or  absorption  from  the  umbilical  vein,  and  also 
from  osteitis  and  periosteitis.  It  may  occur,  too,  in  many  of  the  fevers, 
especially  scarlatina ;  and  I  have  seen  one  case  in  the  course  of  a  severe 
attack  of  mumps.  Tubercular  pericarditis,  though  very  rare  as  the  only 
tuberculosis  of  the  thorax,  is  not  seldom  seen  in  connection  with  similar 
affection  of  the  lung,  pleura  or  bronchial  glands,  or  of  the  cranial  and 
abdominal  cavities.  Bright's  disease  may  be  accompanied  by  pericarditis 
which  is  very  often  rapidly  fatal ;  and  some  of  the  scarlatinal  cases  make 
their  appearance  with  signs  of  renal  failure.  Lastly,  pericarditis  is  often 
seen  in  connection  with  severe  pleuropneumonia,  and  purulent  pericar- 
ditis occurs  with  some  cases  of  empyema. 

As  in  pleurisy,  so  in  pericarditis,  the  proportion  of  purulent  to  serous 
effusions  from  all  causes  is  greater  in  childhood  than  in  later  life.  Even 
in  rheumatism  suppurative  pericarditis  may,  I  think,  very  occasionally 
occur — an  exception  to  the  almost  universal  rule  of  serosity  in  rheu- 
matic effusions,  as  also  is  the  still  rarer  purulent  pleurisy.  A  chronic 
effusion  into  the  pericardium  may  be  purulent  and  point  at  the  surface. 
In  such  cases  there  may  be  the  greatest  difficulty  in  making  a  positive 
diagnosis. 

Out  of  a  series  of  26  consecutive  cases  of  pericarditis  registered  under 
this  heading  as  the  most  prominent  affection,  apart  from  the  far  more 
numerous  cases  of  pericarditis  as  a  subordinate  symptom  of  rheumatism 
or  other  diseases,  1 7  were  distinctly  rheumatic  and  were  also  associated 
with  valve-disease  ;  four  followed  on  scarlatina  (two  of  them  showing  also 
mitral  regurgitation)  ;  two  on  pleuro-pneumonia ;  one  on  Bright's  disease ; 
one  on  mumps ;  and  one  on  enteric  fever.  This  list,  however,  but  very 
imperfectly  represents  the  proportion  of  pericarditis  in  pleuro-pneumonia, 
for  many  slight  and  some  severe  attacks  occurring  in  this  category  are 
noted  as  complications  of  the  pulmonary  affection.  A  very  large  number 
of  cases  of  pericarditis,  especially  of  the  tubercular  variety,  other  than 
those  of  rheumatic  origin,  are  not  revealed  by  physical  signs,  and  their 
existence  is  established  only  on  post-mortem  examination.  Some  of 
these  may  be  suspected  from  hampered  heart  action ;  and  we  must  always 


PERICARDITIS.  4 1 9 

bear  in  mind  that  acute  pericarditis  generally  connotes  some  involve- 
ment of  the  cardiac  muscle,  which  may  be  indicated  only  by  irregular 
action  of  the  heart  and  altered  or  muffled  sounds. 

The  diagnosis  of  pericardial  effusion  in  childhood  sometimes  presents 
peculiar  difficulties,  owing  to  the  heart  being  nearer  to  the  front  of  the 
chest  than  in  adults,  and  thus  causing  both  impulse  and  sounds  to  be 
less  obscured,  even  in  cases  of  considerable  effusion.  When,  therefore, 
friction  sound  is  absent,  we  have  to  depend  almost  wholly  on  percussion 
for  a  correct  diagnosis.  The  difficulty  of  accurately  deciding  on  the 
causes  of  increased  precordial  dulness,  even  when  there  is  no  concomitant 
affection  of  lung  or  pleura,  is  of  great  practical  importance  in  cases  of 
previous  heart-affection  with  enlargement ;  and  all  experienced  observers 
will  admit  that  very  often  the  ordinary  rules  of  percussional  distinction 
between  an  enlarged  heart  and  pericardial  effusion,  according  to  the  alleged 
scpiareness  of  the  one  and  pyramidal  shape  of  the  other,  most  signally 
fail  us  in  cases  of  any  age,  but  especially  in  children.  I  have  myself 
known  two  cases  of  the  right  heart  and  one  of  the  left  being  tapped, 
with  nevertheless  no  resultant  harm  but  rather  benefit  to  the  patient,  in 
the  expectation  of  finding  a  pericardial  effusion ;  and  I  doubt  not  that 
similar  diagnostic  mistakes  are  more  frequently  made  in  practice  than 
reported  in  print.  Another  error,  not  seldom  made,  of  mistaking  a  peri- 
cardial effusion  for  a  left-sided  pleurisy  is  not  of  much  importance,  and 
is  more  easily  avoided. 

In  respect  of  the  difficulty  of  diagnosis  between  enlargement  of  the 
heart,  especially  on  the  right  side,  and  pericardial  effusion,  the  teaching 
of  Dr.  Eotch1  may  prove  to  be  of  value.  He  concludes  from  many 
experiments  and  observations  that  absolute  dulness  of  any  considerable 
extent  in  the  fifth  right  intercostal  space  means  pericardial  effusion, 
provided  that  other  complications  outside  of  the  heart  and  pericardium, 
such  as  pulmonary  consolidations  and  pleural  effusions  and  adhesions, 
can  be  excluded.  Since  reading  Dr.  Eotch's  paper  I  have  found  this 
dictum  diagnostically  helpful  in  one  case,  which  seemed  to  many  to 
be  pericardial  effusion  until  the  necropsy  disproved  this  view;  but  in 
another  very  doubtful  case,  which  for  several  reasons,  although  diagnosed 
by  others  as  pericardial,  was  regarded  by  me  as  cardiac  enlargement  and 
was  almost  proved  to  be  so  by  the  withdrawal  of  a  drachm  and  a 
half  of  pure  blood  with  marked  relief  of  severe  symptoms,  there  was 
unquestionable  dulness  in  the  right  fifth  interspace.  I  could  not,  how- 
ever, quite  exclude  in  this  case  the  possibility  of  some  pleural  complica- 
tion on  the  right  side;  and  the  child,  who  was  the  subject  of  previous 
heart-disease,  soon  recovered  sufficiently  to  leave  the  hospital. 

1  Article  "Diseases  of  Pericardium,"  vol.  ii.  of  Keatiug's  Cyclopeedia  of  the 
Diseases  of  Children. 


420  DISORDERS  OF  THE  HEART  AND  CIRCULATION. 

It  may  be  hoped  that  further  observations  may  test  the  value  of  this 
possible  diagnostic  aid.  For  the  rest,  the  matter  of  detection  of  peri- 
carditis is  much  the  same  in  children  as  in  adults,  though  large  effusions 
more  often  cause  prominence  of  the  heart  region.  Double  friction-sound 
of  no  valvular  localisation,  but  chiefly  marked  at  the  base  in  early  cases, 
is  the  most  certain  sign ;  but  it  must  be  remembered  that  pericardial 
sounds,  when  not  rough,  may  be  sometimes  mistaken  for  a  double  aortic 
murmur.  When  the  sound  is  systolic  only  it  may  be  more  easily 
mistaken  as  valvular,  especially  when  localised  at  the  base  and  devoid 
of  that  prevalent  quality  which  has  led  to  the  somewhat  misleading  use 
of  the  terms  "friction"  and  "pericardial"  as  synonymous  in  their  ap- 
plication to  sounds.  In  all  doubtful  cases  of  this  kind  we  should  defer 
our  forecast  as  to  permanent  damage  until  repeated  examination  has 
been  made. 

The  immediate  prognosis  in  acute  pericarditis  is  as  a  rule  good  in 
children  as  regards  approximate  recovery,  with  the  marked  exception 
of  cases  occurring  in  Bright's  disease,  which,  as  in  adults,  are  most  often 
rapidly  fatal.  It  is  very  rare  for  a  young  child  to  die  from  the  imme- 
diate effects  of  a  rheumatic  pericardial  effusion,  however  large  it  may 
appear,  provided  there  be  not  much  pre-existing  heart  disease ;  but  a 
fresh  pericarditis,  even  without  much  liquid  effusion,  supervening  on 
old  heart  mischief,  and  especially  when  accompanied  by  fresh  pleurisy,  is 
of  very  grave  and  sometimes  fatal  import.  Doubtless  many  of  the 
severe  symptoms  of  failing  circulation  which  occur  with  pericarditis 
of  a  seemingly  small  extent  are  due  to  a  greater  or  less  involvement 
of  the  heart  muscle ;  and,  seeing  that  pericarditis  in  children  is  almost 
always  attended  by  valve-disease,  the  prognosis  largely  depends  on  the 
consecutive  damage  to  the  heart  from  this  cause.  In  all  chronic  cases  a 
knowledge  of  their  course  from  continued  observation  is  necessary  before 
a  useful  forecast  for  any  lengthened  period  can  be  given. 

Cases  of  what  has  been  termed  mediastino-pericarditis  have  been 
reported  by  Drs.  Ashby  and  Hutton,  consisting  for  the  most  part  of 
an  extension  of  pleuro-pericarditis  to  the  mediastinal  connective  tissue, 
sometimes  involving  the  mediastinal  glands,  and  leading  to  matting 
together  of  the  pleura,  pericardium  and  great  vessels.  This  inflammatory 
process  may  be  of  various  extent,  and  the  indurated  tissue  may  be  very 
thick.  •  Such  cases  are  often  tubercular  and  associated  with  caseous 
mediastinal  glands,  but  they  are  certainly  sometimes  unconnected  with 
tubercle.  The  symptoms  are  those  of  labouring  heart,  imperfect  filling 
of  the  lungs,  and  pressure  on  the  large  veins  entering  the  chest.  In 
some  cases  which  I  have  observed  there  has  been  an  extensive  but 
ill-defined  area  of  dulness  above  the  base  of  the  heart.  In  these,  as 
in  those  described  by  the   authors   above  quoted,  there  was  hurried 


PERICARDITIS.  42  I 

breathing  and  blueness  of  face  on  exertion  with  a  tendency  to  enlarged 
veins  on  the  neck  and  chest ;  and,  in  one,  clubbing  of  the  finger-tips. 
In  the  graver  cases  there  may  be  general  oedema  with  ascites  and 
enlarged  liver.  I  had  one  post-rheumatic  case  under  observation  for 
several  years,  where  the  less  grave  symptoms  and  considerable  dulness 
in  the  upper  sternal  region  were  well  marked.  The  boy,  otherwise 
healthy,  was  always  somewhat  distressed  and  slightly  cyanosed  on 
violent  exertion,  and  occasionally  had  slight  syncopic  attacks  which  were 
certainly  not  of  an  epileptic  character. 

In  the  treatment  of  pericarditis  the  chief  attainable  objects  are  rest 
for  the  hampered  heart  and  relief  of  pain,  for  we  cannot  greatly  hope 
to  arrest  the  inflammatory  process.  At  the  onset,  however,  I  usually 
blister  over  the  praecordium,  and  give  full  doses  of  opium,  which,  besides 
relieving  pain,  may  have  an  anti-inflammatcry  effect.  In  severe  cases 
leeching  over  the  praecordium  may  be  useful.  If  the  heart-action  indicate 
it,  by  a  combination  of  frequency,  irregularity  and  feebleness  of  contrac- 
tion, digitalis  may  be  given;  but  this  drug  and  its  clinical  associates 
are,  I  think,  quite  useless  and  possibly  harmful  if  the  pulse,  although 
frequent,  be  of  good  quality  and  rhythm.  The  salicylates  and  salicin 
are  to  be  avoided  if  heart-trouble  be  marked,  as  already  insisted  on  in 
connexion  with  endocarditis,  but  are  not  contra-indicated  in  rheumatic 
attacks  if  the  heart  be  working  easily. 

Paracentesis  pericardii  is  very  rarely  necessary.  The  question  will 
arise  only  in  cases  of  acute  and  rapid  effusion  with  urgent  symptoms 
where  relief  may  reasonably  be  expected,  or  when  we  believe  the 
effusion  to  be  purulent.  After  a  diagnostic  puncture  a  free  incision  may 
then  be  made  and  a  drainage-tube  inserted.  In  rheumatic  pericarditis 
indications  for  paracentesis  are  rarely  offered. 

If  paracentesis  be  decided  on,  a  fine  aspirating  trocar  should  be  used 
and  any  forthcoming  fluid  slowly  withdrawn.  Should  a  mistake  in 
diagnosis  have  been  made  the  abstraction  of  a  drachm  or  two  of  blood 
from  the  heart  will  not  be  harmful  •  it  has,  indeed,  been  in  some  cases 
positively  beneficial.  I  have  once,  as  already  stated,  almost  deliberately 
tapped  the  right  heart  in  a  case  where  some  had  made  the  diagnosis 
of  pericardial  effusion ;  and  I  can  see  no  reason  why  future  experience 
may  not  establish  the  operation  as  an  easy,  safe  and  speedy  means,  espe- 
cially in  the  case  of  children,  of  relieving  those  symptoms  for  which  we 
usually  practise  venesection  or  cupping.  At  present,  however,  I  am  not 
in  a  position  to  discuss  in  detail  or  definitely  advocate  this  procedure, 
which  only  further  experience  could  duly  accredit. 

If  the  contention  of  Dr.  Rotch,  regarding  the  positive  diagnostic  value 
in  pericardial  effusion  of  considerable  dulness  in  the  fifth  right  intercostal 
space,  be  corroborated  by  general  experience,  his  further  suggestion  that 


42  2  DISORDERS  OF  THE  HEART  AND  CIRCULATION. 

this  is  the  right  spot  for  paracentesis  is  a  practical  one.  The  usual  place 
chosen  at  present  is  the  fourth  or  fifth  left  intercostal  space,  midway 
"between  the  left  sternal  horder  and  the  nipple-line. 

All  patients  who  have  had  pericarditis  with  symptoms  should  he  kept 
in  hed  after  the  febrile  time  for  a  period  to  be  defined  by  careful  physi- 
cal examination  and  observation  of  the  heart's  functions. 


CHAPTER  IV. 
Raynaud's   disease. 

It  is  perhaps  best  for  clinical  reasons  to  mention  this  curious  malady 
here,  rather  than  relegate  it,  according  to  prevalent  custom,  to  the  domain 
of  skin-affections.  It  appears  to  be  at  least  proximately  due  to  local  fail- 
ures of  circulation,  and  the  tendency  to  it  would  seem  to  be  congenital 
in  some  cases.  But  little  or  nothing  of  practical  value  can  be  said  con- 
cerning the  aetiology  of  this  remarkable  form  of  circulatory  stasis  or  gan- 
grene, which  must  often,  perforce,  be  called  idiopathic.  It  has  been 
attributed  to  spasm  of  arterioles,  to  peripheral  neuritis,  and  to  functional 
nerve  disturbance ;  and,  from  some  of  its  associations,  especially  with 
hsemoglobinuria  and  to  some  extent  with  the  rare  affection  in  new-born 
infants  known  as  Winckel's  disease,  it  might  perhaps  in  some  instances 
be  plausibly  referred  to  microbic  origin. 

The  affection  is  most  often  though  not  always  of  symmetrical  distribu- 
tion. It  usually  attacks  the  toes  or  fingers,  and  sometimes  the  ears,  scro- 
tum, vulva  or  other  parts.  The  affected  region  is  at  first  cold  and 
yellowish  white  or  livid  in  hue,  and  may  be  painful,  tender  and  hard ; 
but  sometimes  it  is  quite  anaesthetic.  The  arterial  pulsation  in  the  suf- 
fering limbs  is  not  usually  affected,  but  in  some  cases  has  been  notably 
lessened.  There  is  frequently  some  fever,  with  headache  and  anorexia. 
In  the  slighter  cases  the  parts  soon  return  to  the  normal  condition  by 
means  of  warmth,  but  in  others  gangrene  often  sets  in  and  more  or  less 
sloughing-away  is  the  final  result.  In  almost  all  instances  there  is  a 
tendency  to  recurrence  of  attacks  at  different  intervals,  at  least  for  a  time, 
and  in  many  a  previous  history  of  liability  to  suffer  from  cold  extremi- 
ties. Taking  into  consideration  the  cases  of  this  disease  which  are  asso- 
ciated with  paroxysmal  hsemoglobinuria,  it  seems  clear  that  exposure  to 
cold  is  at  least  a  frequent  exciting  cause  of  attacks.  Eaynaud  teaches 
that  the  affection  is  due  to  spasm  of  arterioles  excited  by  cold,  and  him- 


RAYNAUD  S  DISEASE.  423 

self  observed  contraction  of  the  retinal  arteries.  The  various  degrees  or, 
in  some  cases,  stages  of  the  affection  are  denominated  local  syncope,  local 
asphyxia,  and  gangrene.  In  the  most  advanced  form  the  disease  is  rare  ; 
but  attacks  of  chilly  pallor  or  blueness  of  the  extremities,  neither  very 
intense  nor  proceeding  to  gangrene,  are  not  very  rare  in  children,  at  least 
among  the  hospital  classes.  The  blueness  sometimes  extends  up  the 
arms  and  legs.  Such  cases  usually  recover  very  soon  with  continuous 
warmth  and  stimulative  treatment.  There  may,  indeed,  be  some  asso- 
ciation between  this  affection  and  the  ordinary  chilblain. 

I  have  seen  a  case  in  a  boy  of  eight,  who  was  in  hospital  for  right 
hip  disease,  contracted  diphtheria  later,  and  then,  after  two  months' 
mechanical  extension  of  his  right  leg,  showed  signs  in  the  toes  of  the 
right  foot  of  commencing  gangrene  which  subsequently  spread  as  far  as 
the  metatarso-phalangeal  line.  At  first  the  appearance  wa3  provisionally 
attributed  to  the  bandaging ;  but  after  a  fortnight  the  toes  of  the  left 
foot  became  affected  as  well  as  the  pinnte  of  both  ears.  In  the  course  of 
the  next  six  weeks,  with  various  fluctuations  of  condition,  all  the  parts 
recovered,  except  the  right  foot,  from  which  most  of  the  phalanges 
sloughed  away. 

Dr.  "W.  Pasteur  has  kindly  shown  me  his  notes  of  a  case  in  a  boy  of 
nine,  where  there  were  several  attacks  of  blueness  and  coldness  and  pain 
in  the  fingers  following  soon  after  a  dog-bite  on  the  back  of  the  hand. 
Some  of  the  attacks  were  very  evanescent.  The  blueness  was  very  deep 
and  extended  sometimes  up  the  fore-arm,  but  usually  only  as  far  as  the 
wrist.  Artificial  chilling  of  the  hand  brought  on  an  attack.  The  left 
radial  pulse  was  frequently  noticed  to  be  smaller  than  the  right  during 
the  attacks,  but  not  at  other  times.  The  boy  recovered  completely  from 
the  affection  after  a  fortnight.  He  was,  however,  the  subject  of  heredi- 
tary syphilis,  and  subsequently  suffered  from  pharyngeal  ulceration  of 
apparently  syphilitic  character.  In  another  case  of  my  own,  in  a  boy  of 
five,  there  were  repeated  attacks  of  pain,  with  deep  blueness  of  extremities, 
amounting  to  blackness  at  the  finger-tips.  In  one  attack  the  left  hand 
and  right  foot  were  affected ;  in  another,  on  the  following  day,  the  left 
hand,  both  ears  and  both  feet ;  and,  one  day  later,  one  foot  only.  Each 
attack  lasted  about  three  or  four  hours.  In  a  month  from  the  first  they 
ceased  entirely.     The  urine  was  normal  throughout. 

I  have  referred,  under  the  heading  of  urinary  affections,  to  two  further 
cases  under  the  care  of  Dr.  AY.  Pasteur,  where  there  was  haemoglobinuria, 
always  excited  by  chill,  in  association  with  blueness  and  chilliness  of  the 
extremities.  These  cases  seemed  to  me  to  be  in  every  way  similar  to 
the  usually,  but  not  always,  malarious  examples  of  paroxysmal  hsemoglobi- 
nuria  with  circulatory  stasis  or  gangrene  of  the  ears  or  extremities,  which 
are  from  time  to  time  met  with  in  adults. 


424  DISORDERS  OF  THE  HEART  AND  CIRCULATION. 

Warmth,  tonics,  and  the  application  of  the  interrupted  galvanic 
current  to  the  affected  limb  by  placing  it,  with  one  of  the  electrodes,  in 
a  mixture  of  warm  water  and  salt,  after  the  practice  of  Dr.  T.  Barlow 
seem  to  be  the  best  modes  of  treatment,  and,  when  established  in  time, 
may  prevent  "local  asphyxia"  proceeding  to  gangrene,  as  appeared  very 
likely  in  one  case  under  my  own  observation. 


INDEX. 


Abdominal  disease,  general  considera- 
tions on  diagnosis  of,  1 15. 

Abscess,  cerebral,  272. 

in  perityphlitis,  81. 

— —  of  liver,  95. 

of  mediastinal  glands,  400. 

■ retropharyngeal,  35,  1S0. 

Acute  febrile  diseases,  161. 

convulsions  in,  232. 

vomiting  in,  40. 

Acute  yellow  atrophy  of  liver,  93. 

Adenoids,  nasal,  338. 

Albuminuria,  causes  of,  107. 

in  diphtheria,  164,  17 1. 

in  intestinal  inflammation,  57. 

in  lardaceous  disease,  1 10. 

in  scarlatina,  180. 

in  tonsillitis,  33. 

Alkalies  in  dyspeptic  vomiting,  42. 

Amyotrophy,  progressive  (see  Progressive 
amyotrophy). 

AnEemia,  148. 

causes  of,  149. 

symptoms  of,  149. 

treatment  of,  150. 

splenic  [see  Splenic  anaemia). 

Anasarca,  causes  of,  108. 

Anchylostoma,  anaemia  from,  149. 

Aortic  disease,  412. 

Aphasia,  248. 

Aphonia,  hysterical,  317. 

in  laryngeal  affections,  340. 

Aphthae,  23. 

Arthritis  deformans,  216. 

treatment  of,  217. 

scarlatinal,  181. 

Artificial  feeding  of  infants,  12. 

"  foods,"  objection  to,  17. 

human  milk,  18. 

Ascites,  88. 

causes  of,  89. 

in  acute  nephritis,  no. 

in  acute  peritonitis,  84. 

in  cirrhosis  of  liver,  94. 

in  tubercular  peritonitis,  87. 

symptoms  of,  89. 

treatment  of,  90. 

Asthma,  359. 

causes  of,  360. 

gouty  heredity  in,  360. 


Asthma,  prognosis  in,  361. 

relation  to  ekzema,  361. 

symptoms  of,  361. 

treatment  of,  361. 

Atelectasis,  354,  365. 

Athetosis,  249,  252. 

Atrophy  from  dietetic  causes  (see  Wast- 
ing)- 

muscular,  in  arthritis  deformans, 

216. 

in  diphtheritic  paralysis,  269. 

in  infantile  spinal  paralysis,   254, 

260. 

in   pseudohypertrophic    paralysis, 

262. 

Aura,  epileptic,  237,  240. 

Bacillus  diphtheria,  166. 

Fraenkel's,  373. 

of  tetanus,  331. 

of  tubercle,  145. 

Bilharzia,  149. 
Bleeders'  disease,  152. 
Blood  in  stools,  60. 

in  intussusception,  74. 

normal  characters  of,  in  childhood, 

15°-. 

Blue  disease  (see  Cyanosis). 
Brain,  abscess  of,  272. 

acute  diseases  of,  271. 

chronic  diseases  of,  2S6. 

tumours  of,  290. 

causes,  291. 

diagnosis,  295. 

gliomatous,  290. 

■ symptoms,  291. 

treatment,  295. 

tubercular,  290. 

Bright's  disease  (see  Nephritis). 

Bronchi,  dilatation  of,  354. 

Bronchial  catarrh,  in  enteric  fever,  203. 

in  measles,  185. 

Bronchitis,  acute,  362. 

causes,  363. 

symptoms,  364. 

treatment  (see  Broncho-pneu- 
monia). 

chronic,  353. 

causes  of,  355. 

■  prognosis  in,  356. 


426 


INDEX. 


Bronchitis,  chronic,  symptoms  of,  354. 

treatment  of,  356. 

Broncho-pneumonia,  365. 

causes,  365. 

in  influenza,  1 98. 

in  measles,  185. 

in  whooping-cough,  221. 

morbid  anatomy  of,  366,  367. 

mortality  in,  368. 

prognosis  in,  369. 

results  of,  370. 

symptoms  of,  366. 

■ treatment  of,  370. 

tubercular,  368,  370. 

Oanceum  oris  (see  Stomatitis,  gangre- 
nous), 26. 

Caries  of  spine  in  struma,  142. 

Catalepsy,  315. 

Catarrh,  gastric  (see  Gastric  catarrh). 

intestinal  (see  Enteritis). 

tracheo-bronchial,  352. 

Catarrhal  pneumonia  (see  Broncho-pneu- 
monia). 

Cerebellum,  tumour  of,  293. 

Cerebral  abscess,  272. 

disease,  vomiting  in,  40. 

embolism,  289. 

haemorrhage,  289. 

tumour,  290. 

Cerebro-spinal  fever,  282. 

Cheyne-Stokes  respiration,  271,  275. 

Chicken-pox,  193. 

diagnosis,  193,  195. 

eruption,  195. 

incubation,  193. 

symptoms,  194. 

Cholera  infantum,  45. 

Chorea,  297. 

causes,  299. 

"  electrica,"  245. 

morbid  anatomy,  304. 

neurotic  history  in,  305. 

"post-hemiplegic,"  249. 

prognosis,  307. 

relation  to  rheumatism,  210,  214, 

300. 

symptoms,  298. 

treatment,  307. 

Clubbing  of  fingers  in  chronic  bronchitis, 

354; 

in  cyanosis,  407. 

in  phthisis,  396. 

Colitis,  63. 

ulcerative,  63. 

Collapse  of  lung  in  whooping-cough,  221. 

sudden  death  from,  6. 

Condylomata,  131. 
Constipation,  67. 

causes  of,  67,  68. 

in  acute  peritonitis,  85. 

in  anaemia,  149. 

in  enteric  fever,  202. 

in  infancy,  68. 


Constipation  in  intestinal  obstruction,  74. 

in  perityphlitis,  81. 

in  tubercular  meningitis,  68,  276. 

symptoms  of,  68-70. 

treatment  of,  69,  Jl. 

Contagiousness  in  infectious  diseases, 
226a. 

Convulsions  at  onset  of  infantile  par- 
alysis, 256. 

of  measles,  185. 

of  scarlatina,  177. 

in  cerebellar  tumour,  294. 

in  cerebral  tumour,  292. 

in  haemophilia,  152. 

in  meningitis,  232,  276. 

in  rickets,  120,  232. 

in  scarlatina,  180. 

in  syphilis,  133. 

in  whooping-cough,  222. 

infantile,  230. 

causes  of,  231. 

morbid  anatomy  of,  234. 

prognosis  in,  233. 

relation  to  epilepsy,  231. 

■ — — to  rickets,  232. 

sequelae,  233. 

— treatment  of,  234. 

Craniotabes,  122. 

Croup  (see  Diphtheria  and  Laryngitis). 

• ■  false,  342. 

true,  346. 

Croupous  pneumonia  (see  Pneumonia, 
acute). 

Cyanosis,  407. 

causes  of,  407. 

prognosis  in,  408. 

symptoms  of,  407. 

treatment  of,  409. 

Dactylitis,  syphilitic,  133. 
Dentition,  21. 

ailments  of,  22. 

convulsions  in,  22. 

diarrhoea  in,  22. 

pyrexia  in,  22. 

treatment  of,  22. 

Desquamation  in  measles,  185. 

in  scarlatina,  182. 

Diabetes,  100. 
Diabetes  insipidus,  100. 
Diarrhoea,  43. 

■  acute,  43. 

causes  of,  43. 

complications  of,  47. 

diagnosis  of,  42. 

microbic  origin  of,  44. 

post-mortem    appearance    in, 

49. 

stools  in,  46. 

symptoms  of,  45. 

treatment  of,  50. 

chronic,  54- 

causes  of,  54- 

stools  in,  54. 


INDEX. 


427 


Diarrhoea,  chronic,  symptoms  of,  54. 

treatment  of,  54. 

nervous,  55. 

summer,  45. 

Diarrhoea  in  broncho-pneumonia,  367. 

in  enteric  fever,  202. 

in  measles,  185. 

in  perityphlitis,  Si. 

in  tubercular  disease  of   intestine, 

66. 

in  tubercular  peritonitis,  87. 

in  whooping-cough,  222. 

Diet  for  infants,  6. 

Diphtheria,  164. 

broncho-pneumonia  in,  370. 

causes  of,  165,  167. 

croup  in,  169. 

diagnosis  of,  169. 

following  scarlatina,  179. 

incubation,  168. 

laryngeal,  169. 

mode  of  infection,  167. 

mortality  in,  172. 

paralysis  in,  170,  267. 

prognosis  in,  172. 

symptoms  of,  168. 

treatment  of,  173. 

Diphtheritic  paralysis,  267. 

causes,  267,  268. 

symptoms,  268. 

— —  treatment,  270. 

Diplococcus,  Fraenkel's,  377. 

Disseminated  sclerosis,  295. 

Dropsy,  causes  of,  107. 

scarlatinal,  109. 

Dysentery,  63. 

Dyspepsia,  38  sqq. 

Dysphagia  from  retro-pharyngeal  ab- 
scess, 36. 

Dyspnoea  from  retro-pharyngeal  abscess, 
36. 

Eclampsia  nutans,  243. 

Ekzema  in  scrofulosis,  142. 

Electrical     reactions,      in     diphtheritic 

paralysis,  268. 

in  infantile  paralysis,  254. 

in  progressive  amyotrophy,  266. 

in    pseudohypertrophic    paralysis, 

263. 
Embolism,  cerebral,  24S,  2S9. 
Empyema,  38 1. 
associated  with  broncho-pneumonia, 

370. 

causes,  3S1. 

diagnosis,  3S5. 

prognosis,  3S6. 

symptoms,  382  sqq. 

treatment,  384,  386. 

Encephalitis,  271. 
Endocarditis,  411. 

causes,  411. 

prognosis,  415. 

symptoms,  414. 


Endocarditis,  treatment,  415. 

ideerative,  413. 

Enteric  fever,  199. 

and  tubercle,  146. 

complications  of,  204. 

diagnosis  of,  205. 

duration,  201. 

mode  of  infection,  200. 

mortality  in,  199. 

symptoms  of,  201. 

temperature  in,  201. 

treatment  of,  206. 

Enteritis,  63. 

symptoms  of,  63. 

treatment  of,  64. 

follicular,  50. 

Enuresis,  10 1. 

causes  of,  101. 

in  hysteria,  314. 

in  rheumatic  subjects,  215. 

treatment  of,  101. 

Epilepsy,  231,  236. 

causes,  238. 

diagnosis,  237. 

prognosis,  240. 

relation  to  hemiplegia,  239. 

to  hysteria,  238. 

treatment,  241. 

Erythema,  rheumatic,  214. 
Examination,  clinical,  of  children,  2, 
336. 

Facies  in  abdominal  disease,  115. 

Fauces,  affections  of,  30. 

Feeding,  artificial,  general  directions,  12. 

Filaria,  149. 

Flexibilitas  cerea,  315. 

"Foods,"  artificial,  objections  to,  17. 

Fraenkel's  bacillus,  373,  377. 

Friedreich's  ataxia,  296. 

Gastric  catarrh,  60. 

causes  of,  60. 

symptoms  of,  61. 

treatment  of,  62. 

dyspepsia,  38. 

flatulence  in,  39. 

thirst  in,  39. 

■  treatment  of,  41. 

vomiting  from,  38. 

wasting  in,  39. 

Gastro-intestinal  disorders,  38. 
German  measles  (sec  Rubella). 
Glandular  enlargement  in  Hodgkin's  dis- 
ease, 149. 

in  rubella,  190. 

in  struma,  141. 

■  in  tonsillitis,  ^2- 

Gliomata,  290. 
Glottic  spasm,  342. 
Gravel,  103. 
Gummata,  137. 

H.#:matemesis,  causes  of,  60. 


428 


INDEX. 


Haematemesis,  in  haemophilia,  152. 

in  purpura,  154. 

Hematuria,  105. 

causes  of,  105. 

in  haemophilia,  152. 

in  purpura,  154. 

in  tubercular  disease  of  kidneys,  1 12. 

Hemoglobinuria,  106. 

infectious,  106. 

paroxysmal,  107. 

Haemophilia,  152. 
Haemoptysis  in  phthisis,  392. 

in  purpura,  154. 

Haemorrhage,  cerebral,  248,  289. 

in  cyanosis,  407. 

in  leucocythsemia,  152. 

meningeal,  247,  289. 

Haemorrhages,  cutaneous,  causes  of,  151. 
Haemorrhagic  diathesis,  152. 

periostitis,  156. 

Harrison's  sulcus,  121. 

Hay-fever,  360. 

Heart,  condition  of,  in  chorea,  299,  301. 

in  diphtheria,  170. 

in  enteric  fever,  203. 

in  rheumatism,  210,  211. 

congenital  disease  of,  407. 

fibroid  disease  of,  in  syphilis,  135. 

functional  disease  of,  405. 

causes,  406. 

symptoms,  406. 

treatment,  406. 

in  children,  normal  physical  signs 

of,  405. 

inflammation  of,  410. 

valvular  disease  of,  41 1. 

Hemichorea,  298. 
Hemicrania,  327. 
Hemiplegia,  247. 

causes,  247. 

in  syphilis,  133. 

prognosis,  250. 

relation  to  epilepsy,  239. 

symptoms,  249. 

Heredity,  in  asthma,  360. 

in  chorea,  305. 

in  chronic  bronchitis,  355. 

in  emphysema,  357. 

in  epilepsy,  238. 

■ ■  in  infantile  convulsions,  232. 

in  rheumatism,  214. 

in  tubercular  meningitis,  273. 

Herpes  in  pneumonia,  375. 
Hodgkin's  disease,  97,  149. 
Hydrocephaloid,  284. 
Hydrocephalus,  acute,  283. 

symptoms,  283. 

— : — treatment,  284. 

chronic,  2S6. 

causes,  287. 

diagnosis,  286. 

morbid  anatomy,  287. 

relation  to  syphilis,  288. 

symptoms,  287. 


Hydrocephalus,  chronic,  treatment,  288. 
Hypnotism,  324. 

Icterus  neonatorum,  91. 

Incubation  in  infectious  diseases,  226a. 

Infantile  spinal  paralysis,  253. 

causes,  254,  255,  258. 

diagnosis,  259. 

electrical  reactions  in,  254. 

following  acute  specific  fevers,  255. 

mode  of  onset,  254. 

morbid  anatomy,  257. 

pathology,  257. 

prognosis,  260. 

symptoms,  254  sqq. 

treatment,  260. 

Influenza,  197. 

diagnosis,  198. 

symptoms,  197. 

treatment,  198. 

Intestinal  obstruction,  73. 
Intestines,  catarrh  of  (see  Enteritis). 

tubercular  disease  of,  65. 

diagnosis  of,  66. 

■ ■ treatment  of,  67. 

Intubation  in  diphtheria,  175. 

in  membranous  laryngitis,  350. 

Intussusception,  73. 

diagnosis  of,  76. 

prognosis  in,  77. 

symptoms  of,  74. 

treatment  of,  78. 

chronic,  74- 

Jaundice,  91. 

in  acute  yellow  atrophy,  93. 

in  childhood,  92. 

in  infancy,  91. 

in  pneumonia,  376. 

malignant,  93. 

Keratitis,  strumous,  142. 

syphilitic,  137. 

Kidney,  calculus  of,  105. 
Kidneys,  diseases  of,  108. 

fibroid  disease  of,  in  syphilis,  135. 

sarcoma  of,  112. 

tubercular  disease  of,  112. 

symptoms,  112. 

-treatment,  112. 

Klebs-Loffler  bacillus,  166. 
Knee-jerks  in  cerebellar  tumour,  294. 

in  diphtheria,  171. 

in  diphtheritic  paralysis,  268. 

• ■  in  infantile  paralysis,  254. 

in  progressive  amyotrophy,  266. 

in    pseudo-hypertrophic    paralysis, 

263. 
in  spastic  paralysis,  252. 

Laparotomy  in  intussusception,  78. 

in  tubercular  peritonitis,  88. 

Lardaceous  disease  of  liver,  94. 
Laryngeal  catarrh,  342. 


IXDKX. 


429 


Laryngismus,  231,  340. 

causes,  341. 

diagnosis,  342. 

■  in  rickets,  120,  341. 

symptoms,  341. 

treatment,  342. 

Laryngitis,  acute,  344. 

catarrhal,  344. 

in  measles,  1S5. 

symptoms,  345. 

treatment,  345. 

membranous,  165,  346. 

■ causes  of,  346. 

diagnosis  of,  348. 

■  prognosis  in,  349. 

relation  to  diphtheria,  346. 

symptoms,  348. 

treatment,  350. 

Larynx,  affections  of,  339  sqq. 

foreign  bodies  in,  340. 

■ ■  cedema  of,  340. 

syphilitic  disease  of,  351. 

tubercular  disease  of,  351. 

warty  growths  of,  339,  351. 

Leucocythsemia,  97,  149. 
"  Lightning-spasm,"  245. 
Lithsemia,  103. 
Liver,  abscess  of,  95. 

acute  yellow  atrophy  of,  93. 

cirrhosis  of,  94. 

diseases  of,  91. 

treatment,  96. 

enlargement  of,  £9,  95. 

fatty,  94. 

■ ■  in  rickets,  124. 

in  splenic  anaemia,  98. 

in  syphilis,  134. 

lardaceous,  94. 

size  of,  in  children,  95. 

tumours  of,  95. 

Lobar  pneumonia  (sec  Pneumonia,  acute). 
Lobular  pneumonia   (see   Broncho-pneu- 
monia). 
Lung,  collapse  of,  221,  354,  365. 

• fibroid  disease  of,  in  syphilis,  135. 

Lymphadenoma,  97,  149. 

Measles,  184. 

and  tuberculosis,  145,  1S6,  280. 

complications  of,  186  sqq. 

contagium  of,  188. 

diagnosis  of,  187. 

incubation,  188. 

■  infantile  paralysis  after,  255. 

paralysis  in,  186. 

retropharyngeal  abscess  in,  36. 

symptoms  of,  184. 

treatment  of,  188. 

Measles,  German  (see  Rubella). 
Mediastinal  glands,  diseases  of,  400. 

causes,  400. 

symptoms,  400. 

Mediastino-pericarditis,  420. 
Melrena,  60,  64. 


Melaena,  causes  of,  64. 

diagnosis  of,  65. 

in  haemophilia,  152. 

in  purpura,  154. 

treatment  of,  65. 

Membranous    laryngitis    (see  Laryngitis, 

membranous). 
Meningitis,    distinguished    from   enteric 

fever,  205. 

epidemic  cerebro-spinal,  282. 

idiopathic,  281. 

non-tubercular,  280. 

purulent,  282. 

tubercular,  272. 

causes,  273. 

diagnosis,  274. 

duration,  27S. 

morbid  anatomy,  279. 

pathology,  280. 

symptoms,  274. 

treatment,  284. 

Milk,  artificial  human,  18. 

ass's,  11. 

cow's,  11. 

goat's,  11. 

human,  composition  of,  6. 

sterilising  of,  14. 

Mitral  disease,  412. 
Morbilli  (see  Measles). 
Mouth,  affections  of,  21. 
Mumps,  195. 

diagnosis,  195. 

■ incubation,  196. 

symptoms,  196. 

treatment,  196. 

Murmurs,  cardiac,  in  anaemia,  149. 

in  chorea,  299. 

in  valvular  disease,  414. 

Myocarditis,  410. 

Naphthalene  and  naphthol  in  diarrhoea, 

■  in  enteric  fever,  20S. 

Nasal  adenoids,  338. 

catarrh,  337. 

Nephritis,  acute,  109. 

cause  of,  no. 

following  chicken-pox,  194. 

in  lardaceous  disease,  no. 

prognosis  in,  no. 

symptoms  of,  109. 

treatment  of,  III. 

chronic,  no. 

■ ■  in  lardaceous  disease,  no. 

scarlatinal,  109,  1S0. 

Nervous  system,  diseases  of,  229  sqq. 
Night-terrors  in  hysteria,  314. 

in  rheumatic  subjects,  215. 

Nodding-spasm,  243. 
Nodules,  rheumatic,  213,  413. 
Noma  (sec  Stomatitis,  gangrenous). 
Nose,  affections  of,  337. 
Nystagmus,  242. 
causes,  242. 


430 

Nystagmus  in  cerebral  tumour,  292. 

in  spastic  paralysis,  252. 

in  tubercular  meningitis,  276. 

Obstkuction,  intestinal,  73. 
(Edema  of  feet  in  anaemia,  149. 

in  nephritis,  109. 

in  tuberculosis,  147. 

Oliguria,  101. 

Ophthalmia,  strumous,  142. 

Optic  atrophy  in  hydrocephalus,  287. 

neuritis  in  cerebral  tumour,  292. 

in  tubercular  meningitis,  279. 

Orchitis  in  mumps,  196. 
Otitis,  329. 

causes,  339. 

in  measles,  1 86. 

in  scarlatina,  178. 

interna,  330. 

media,  329. 

symptoms,  330. 

treatment,  330. 

Ozcena,  337. 

in  scrofulosis,  1 42. 

Pancreas,  disease  of,  in  syphilis,  135. 

Papillomata  of  larynx,  339,  351. 

Paracentesis  in  empyema,  387. 

in  pericarditis,  421. 

in  pleurisy,  386. 

Paralysis,  247. 

diphtheritic,  170,  267. 

facial,  after  otitis,  330. 

hemiplegic  (see  Hemiplegia). 

hysterical,  317. 

infantile  {see  Infantile  spinal  par- 
alysis). 

in  measles,  186. 

pseudohypertrophic,  262.  _ 

spastic  [see  Spastic  paralysis). 

Paratyphlitis,  80. 

Parotiditis,  contagious  [see  Mumps). 

in  acute  febrile  diseases,  196. 

Pemphigus  following  chicken-pox,  194.^ 

Perforation    of    bowel    in   perityphlitis, 
82. 

Pericardial  effusion,  417  sqq. 

Pericarditis,  417. 

causes,  417. 

■ diagnosis,  419. 

in  acute  nephritis,  IIO,  418. 

prognosis,  420. 

septic,  418. 

symptoms,  417. 

treatment,  421. 

tubercular,  418. 

Peritonitis,  acute,  83. 

causes  of,  84. 

diagnosis  of,  85. 

prognosis  in,  85. 

symptoms  of,  84. 

treatment  of,  85. 

chronic,  86. 

tubercular,  86. 


INDEX. 


Peritonitis,  tubercular,  diagnosis  of,  87. 

symptoms  of,  86. 

treatment  of,  88. 

Perityphlitis,  79. 

causes  of,  80. 

symptoms  of,  81. 

treatment  of,  82. 

Petit  mal,  240. 

Pharynx,  acute  catarrh  of,  30. 

Phthisis,  389. 

chronic,  394. 

diagnosis,  393. 

fibroid,  394. 

morbid  anatomy,  390. 

symptoms,  392. 

treatment,  398. 

varieties,  391. 

Pleurisy,  379. 

causes,  381. 

diagnosis,  385. 

in  rheumatism,  210,  213. 

results,  384. 

symptoms,  380,  382. 

treatment,  386. 

Pneumonia,  acute,  372. 

bacilli  of,  373. 

causes  of,  372. 

diagnosis  of,  377. 

from  enteric  fever,  205. 

epidemic,  373. 

mortality  in,  375,  378. 

symptoms  of,  373. 

treatment  of,  379. 

vomiting  in,  41. 

caseous  (see  Phthisis). 

catarrhal  (see  Broncho-pneumonia). 

lobular  (see  Broncho-pneumonia). 

Poliomyelitis  anterior  (see Infantile  spinal 

paralysis). 
Polyuria,  1 00. 
Pons,  tumour  of,  292. 
Progressive  amyotrophy,  265. 

juvenile  type,  266. 

■  peroneal  type,  265. 

pathology,  266. 

symptoms,  266. 

Prolapse  of  rectum,  79. 
Pseudo-hypertrophic  paralysis,  262. 

diagnosis,  265. 

pathology,  264. 

symptoms,  262. 

treatment,  265. 

Pseudo-paralysis,  syphilitic,  1 32. 
Pulse  in  diphtheria,  172. 

in  enteric  fever,  203. 

in  scarlatina,  181. 

in  tubercular  meningitis,  275. 

Pulse-rate  in  children,  405. 
Purpura,  1 5 1. 

fulminans,  153,  178. 

hasmorrhagica,  152. 

prognosis  in,  155- 

rheumatica,  153. 

simplex,  152. 


INDEX. 


431 


Purpura,  symptoms  of,  153. 

syphilitic,  135. 

treatment  of,  155. 

Purpuric  eruptions,  causes  of,  151. 

from  drugs,  152. 

■  in  measles,  187. 

in  tuberculosis,  147. 

Pyrexia,  161. 

causes  of,  161. 

from  constipation,  70. 

general  considerations  on,  161  sqq. 

in  infantile  paralysis,  255. 

in  otitis,  329. 

nervous,  162,  321. 

Pyuria,  in  renal  calculus,  105. 

in  tubercular   disease   of   kidneys, 

112. 

Quinsy  {see  Tonsillitis,  acute). 

Rash,  in  chicken-pox,  194. 

in  diphtheria,  171. 

■ ■  in  enteric  fever,  203. 

in  measles,  184. 

in  rubella,  190. 

in  scarlatina,  178. 

prodromal,  in  enteric  fever,  203. 

in  measles,  187. 

with  pyrexia,  164. 

Raynaud's  disease,  422. 

causes,  422. 

symptoms,  422. 

treatment,  424. 

Rectum,  prolapse  of,  79. 
Relapse  in  enteric  fever,  204. 

in  measles,  188. 

in  scarlatina,  181. 

Renal  calculus,  105. 

Resection  of  rib  in  empyema,  387. 

Retraction  of  head,  246. 

causes,  246. 

in  retro-pharyngeal  abscess,  36. 

in  tubercular  meningitis,  276. 

Retro-pharyngeal  abscess,  35. 

causation  of,  36,  180. 

diagnosis  of,  36,  37. 

situation  of,  35. 

symptoms  of,  36,  37. 

treatment  of,  37. 

Rheumatism,  209. 

causes,  209. 

duration,  210. 

pathology,  209. 

prognosis,  214. 

relation  to  chorea,  299. 

scarlatinal,  181,  209. 

symptoms,  209. 

treatment,  215. 

Rheumatoid    arthritis  {see  Arthritis  de- 
formans). 
Rhinitis  in  scarlatina,  180. 
Rickets,  119. 

acute,  126. 

causes  of,  125. 


Rickets,  chronic  bronchitis  in,  355. 

convulsions  in,  232. 

duration  of,  123. 

dyspeptic  vomiting  in,  40. 

morbid  anatomy  of,  124. 

skull  in,  122. 

symptoms  of,  119  sqq. 

treatment  of,  127. 

Rickety  rosary,  121. 

Rose-spots,  in  cerebro-spinal  meningitis, 
282. 

in  enteric  fever,  203. 

in  tubercular  meningitis,  278. 

Rotheln  {see  Rubella). 
Round-worms,  113, 

■  symptoms  with,  113. 

treatment  of,  113. 

Rubella,  189. 

definition,  189. 

diagnosis,  192. 

incubation,  191. 

"scarlatinosa,"  191. 

symptoms,  191. 

. treatment,  192. 

"  Salaam-convulsions,"  243. 
Sarcoma  of  brain,  291. 

of  mediastinal  gland,  400. 

Scarlatina,  177. 

complications  of,  178  sqq. 

contagium  of,  182. 

diagnosis  of,  177,  179. 

incubation,  182. 

inunction  in,  183. 

latent,  177. 

malignant,  180. 

nephritis  in,  109,  1S0. 

prognosis  of,  18 1. 

retro-pharyngeal  abscess  in,  36,  180. 

symptoms  of,  17S. 

treatment  of,  183. 

Scarlatinal  rheumatism,  18 1,  209. 
Sclerosis,  disseminated,  295. 
Scorbutus  {see  Scurvy). 
Scrofulosis,  140. 

causes  of,  141. 

chronic  bronchitis  in,  355. 

definition  of,  141. 

dj'speptic  vomiting  in,  39. 

relation  to  tubercle,  140. 

symptoms  of,  142. 

■ ■  treatment  of,  143. 

Scurvy,  156. 

causes  of,  156. 

treatment  of,  157. 

Scurvy-rickets,  124. 

Skin  affections  in  syphilis,  13 1. 

Skull  in  hydrocephalus,  287. 

in  rickets,  122. 

in  syphilis,  132. 

natiform,  133. 

Snuffling  in  syphilis,  13 1. 
Spasm,  localised,  242. 
prognosis,  245. 


432 


INDEX. 


Spasm,  treatment,  245. 
Spasmodic  disorders,  230. 
Spastic  paralysis,  250. 
causes,  252. 

prognosis,  253. 

treatment,  253. 

with  hemiplegia,  251. 

Spleen,  enlargement  of,  97. 

causes,  97. 

diagnosis,  97. 

in  enteric  fever,  202. 

in  rickets,  124. 

in  syphilis,  134. 

Splenic  ansemia,  98. 

■ symptoms  of,  98. 

treatment  of,  98. 

Stomach,  affections  of,  60. 

cancer  of,  60. 

catarrh  of,  60. 

ulceration  of,  60. 

Stomatitis,  23. 

aphthous,  23. 

■ gangrenous,  26. 

• broncho-pneumonia  in,  26,  370. 

causes  of,  27. 

diarrhoea  in,  26. 

in  measles,  186. 

in  scarlatina,  180. 

■ symptoms  of,  26. 

treatment  of,  27. 

ulcerative,  24. 

causes  of,  24. 

in  measles,  187. 

■ micro-organisms  in,  25. 

symptoms  of,  25. 

treatment  of,  25. 

Stools,  appearance  of,  48,  49. 

effect  of  drugs  on,  49. 

in  acute  diarrhoea,  46,  48. 

in  chronic  diarrhoea,  55. 

blood  in,  60. 

in  intussusception,  74. 

Strabismus  in  acute  hydrocephalus,  283. 

in  diphtheria,  170. 

in  pneumonia,  374. 

in  tubercular  meningitis,  274. 

Stridor,  respiratory,  35. 

in  retro-pharyngeal  abscess,  37. 

Struma  (see  Scrofulosis). 
Summer  diarrhoea,  45. 
Syphilis,  129. 

■ congenital,  129. 

dyspeptic  vomiting  in,  40. 

hydrocephalus  in,  288. 

prognosis  in,  137. 

relapse  in,  136. 

symptoms  of,  129  sqq. 

treatment  of,  138. 

Tabes,  hereditary,  296. 
Tache  cerebrale,  204,  277. 
Tape-worm,  103. 

treatment  of,  103. 

Teeth  in  syphilis,  137. 


Teeth,  milk,  eruption  of,  21. 
Teething  (see  Dentition). 
Temperature  in  children  (see  Pyrexia). 

subnormal,  161. 

Terrors,  night  (see  Night  Terrors). 
Tetanus,  331. 

bacillus  of,  331. 

causes  of,  331. 

diagnosis  of,  332. 

idiopathic,  331. 

neonatorum,  331. 

■ pathology  of,  331. 

prognosis  in,  332. 

■  treatment  of,  332. 

Tetany,  235. 

in  rickets,  120. 

treatment,  236. 

Thirst  in  gastric  dyspepsia,  39. 
Thread-worms,  113. 

symptoms,  113. 

treatment  of,  114. 

Throat  in  diphtheria,  169. 

in  measles,  185- 

in  scarlatina,  179. 

in  tonsillitis,  32. 

Thrombosis,  cerebral,  248,  289. 
Thrush,  28. 
Tonsillitis,  acute,  31. 

causes  of,  31. 

■ diagnosis  of,  32. 

prognosis  in,  33. 

relation   to    rheumatism,    31, 

210. 

■ temperature  in,  33. 

treatment  of,  33. 

chronic,  34. 

in   connection    with   adenoid 

growths,  34. 

with  psoriasis,  34. 

treatment  of,  35. 

Tonsils,  enlargement  of,  in  struma,  141. 
Torticollis,  243. 

in  rheumatism,  210. 

treatment  of,  244. 

Tracheotomy  in  diphtheria,  173. 

in  measles,  185. 

in  membranous  laryngitis,  350. 

Tubercle,     abdominal    (see     Peritonitis, 

Tubercular). 

and  scrofulosis,  140. 

bacillus,  145. 

Tubercular  disease  of  intestines,  65. 

of  kidneys,  112. 

of  stomach,  60. 

meningitis  (see  Meningitis). 

■ tumour  of  brain,  290. 

Tuberculosis,  144. 

• acute  general,  144. 

acute  miliary,  of  lung,  391. 

causes  of,  145. 

chronic,  146. 

definition  of,  144. 

diagnosis  of,  147. 

inheritance  in,  145. 


INDEX. 


433 


Tuberculosis,  prognosis  in,  I47. 

relation  to  measles,  1S6. 

symptoms  of,  147. 

treatment  of,  148. 

Typhlitis  (see  Perityphlitis). 
Typhoid  fever  (sec  Enteric  fever). 

Ulceration  of  intestines,  63,  66. 

of  stomach,  60. 

Uraemia,  109. 

in  scarlatina,  180. 

Urates,  deposit  of,  103. 

causes  of,  103. 

symptoms  with,  104. 

treatment  of,  105. 

Urinary  disorders,  100. 

Urine,  albumen  in  (see  Albuminuria). 

incontinence  of  (see  Enuresis). 

in  infantile  paralysis,  254. 

suppression  of,  in  diphtheria,  172. 

Varicella  (see  Chicken-pox). 
Vomiting,  38. 

dyspeptic,  38. 

causation  of,  39. 

diagnosis  of,  40. 

in  rickets,  40. 

in  scrofula,  39. 

■  in  syphilis,  40. 

treatment  of,  41. 

in  acute  febrile  diseases,  40. 

— — -  in  acute  nephritis,  109. 

in  acute  peritonitis,  85. 

in  cerebral  disease,  40,  275,  292. 

in  diphtheria,  172. 

in  hysteria,  315. 

in  intestinal  obstruction,  41. 

in  intussusception,  74. 

in  measles,  184. 

in  migraine,  326. 

in  pertussis,  40. 


Vomiting,  in  perityphlitis,  81. 

in  pneumonia,  373. 

in  scarlatina,  178. 

in  tubercular  meningitis,  275. 

in  tubercular  peritonitis,  86. 

in  whooping-cough,  221. 

nervous,  41. 


Warty  growths  of  larynx,  339,  351. 
Wasting,  infantile,  5. 

constipation  in,  20. 

diarrhoea  and  vomiting  in,  20. 

post-mortem  appearances  of,  9. 

symptoms  of,  8. 

treatment  of,  10,  21. 

in  cerebral  tumour,  292. 

in  empyema,  382. 

in  gastric  dyspepsia,  39. 

in  rickets,  1 20. 

in  syphilis,  130. 

in    tubercular   disease  of   kidneys, 

112. 

in  tubercular  peritonitis,  86. 

Whooping-cough,  218. 

and  tubercle,  146. 

complications,  221. 

contagiousness  of,  220. 

course,  219. 

hemiplegia  in,  248. 

incubation,  221. 

mode  of  infection,  219. 

prognosis,  223. 

quarantine,  225. 

sequelae,  222. 

symptoms,  219. 

treatment,  223. 

with  measles,  222. 

Winckel's  disease,  106. 

Worms,  113. 

Wry-neck  (see  Torticollis). 


THE   END. 


2  E 


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